1-s2.0-S1873959808700449-main

8/13/2019 1-s2.0-S1873959808700449-main

http://slidepdf.com/reader/full/1-s20-s1873959808700449-main 1/7

International Journal of Gerontology | September 2008 | Vol 2| No 3 91

Introduction

Burn injuries are the principal reason accounting foremergency department admissions. Based on 2002data reported by the Bureau of National HealthInsurance (Taiwan), 178,975 burn patients, i.e., 0.8% ofthe total Taiwanese population, were registered formedical treatment. According to one epidemiologicsurvey of burn injuries in Taiwan, the overall mortality

rate of burn injuries and incidence of catastrophic andhospitalized burns showed a decreasing trend, andthe incidence of ambulatory burns showed an increas-ing trend1. Advances in medical progress and modernburn care have contributed to these changes over the

last two decades, and these include the advent of top-ical treatment, improved resuscitation, modern hemo-dynamic monitoring, adequate nutritional support,and early tangential excision and grafting.

Advances in medical care and longevity have resultedin an increase in the elderly population, and burn inju-ries in this subset of the population are becoming moreprevalent. Elderly patients over 65 years of age consti-tute between 13% and 20% of admissions to burn units,

but have the highest death rate among that of the over-all burn population2,3. Among the number of burndeaths in 2002, the elderly group accounted for 30.3%of the all-age population in Taiwan4. The risk of deathfrom a major burn is associated with increased burnsize, increased age, the presence of a full-thicknessburn, the presence of inhalation injury, and femalegender3,5. Management of elderly burn patients remainsa difficult challenge for clinicians. The current article willreview the modern trend of management of elderlyburn patients.

MANAGEMENT OFELDERLYBURN PATIENTS

Shin-Bin Huang1, Wen-Han Chang1,2,3,4*, Chein-Hsuan Huang5, Cheng-Ho Tsai61Emergency Department, Mackay Memorial Hospital, 2National Taipei University of Technology,

3Mackay Medicine, Nursing and Management College,4Graduate Institute of Injury Prevention and Control,Taipei Medical University,5Department of Rehabilitation, Tai-En Memorial Hospital, and 6 Section of Cardiology,

Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.

SUMMARY

Burn injuries are the principal reasons accounting for emergency department admissions in elderly patients.Elderly patients over 65 years of age constitute between 13% and 20% of admissions to burn units, but havethe highest death rate among the overall burn population. Among the number of burn deaths in 2002, theelderly group accounted for 30.3% of the all-age population in Taiwan. The risk of death from a major burn isassociated with increased burn size, increased age, the presence of a full-thickness burn, the presence ofinhalation injury, and female gender. Management of elderly burn patients remains a difficult challengefor clinicians from clinical, rehabilitative, social and ethical perspectives. Concerning the unique physiologicand metabolic changes in geriatric patients, it is imperative that a well-organized, protocol-driven approach toprovide for proper medical care be considered. The current article will review the management of ongoingeffective health prevention procedures, which necessitates focusing on both prevention and damage limitationwith the aim of a reduction in thermal events in the elderly. [International Journal of Gerontology 2008;2(3): 91–97]

Key Words: aged, burns, fluid therapy, mortality, resuscitation

*Correspondence to: Dr Wen-Han Chang, 92,Section 2, Chungshan North Road, Taipei, Taiwan.Email: [email protected]: June 12, 2008

■ REVIEW ARTICLE

© 2008 Elsevier.

8/13/2019 1-s2.0-S1873959808700449-main


Epidemiology of Elderly Burn Patients

Flame is the main cause of burn injury. Other causes,

in order, include scalds, thermal contact, inhalation, hotfat and immersion. The majority of elderly burns occurat home, most commonly in the kitchen followed bythe bathroom and living room. The majority of burnsin the elderly is caused by carelessness and they areprobably preventable.

Sensory and cognitive impairment in later life andpreexisting medical conditions may lead to a decreasedability of the elderly to identify the severity of the situ-ation as well as a reduced capacity to escape from harm6.This, in turn, may increase vulnerability more than pre-dicted, resulting in larger burn size, deeper burns andan increased risk of inhalation injury.

Elderly burn patients suffer from greater morbidityand mortality than younger patients with similar burnsize as a result of the risk factors prevalent in the eld-erly, including premorbid conditions (e.g., diabetes,cardiovascular diseases), decreased pulmonary reserve,protein-energy malnutrition, unintentional weight loss,decreased lean body mass, impaired response to infec-tion and sepsis, thinner skin, poorer microcirculation,

and increased susceptibility to infection.

Fluid Resuscitation for Elderly Burn Patients

Most clinicians resuscitate patients with burns greaterthan 15% of total body surface area (TBSA) in adultsand 10% of TBSA in children. Fluid resuscitation canbe critical to the development of decreased tissue per-fusion, multiple organ failure, sepsis, and mortality;hence, predicted fluid resuscitation constitutes a critical

component of the early care of the burn patient. Thereare several fluid resuscitation formulae available for theburn patient during the initial period of volume resus-

citation (Table 1)7. The Parkland formula is the favoriteof most surgeons and emergency physicians. Mean arte-rial pressure (MAP) and adequate urine output (UOP)are the most reliable measures of adequate tissue per-fusion. To ensure adequate fluid resuscitation, it is thegoal to maintain MAP above 60mmHg and an UOP of0.5–1.0 mL/kg/hr or 30 mL/hr. For burn patients withmyoglobinuria, osmotic diuresis with mannitol maybe required to achieve an UOP of 100mL/hr. In addition,larger volumes of resuscitation fluid were also identifiedas a risk factor for injury complications and death8.

Underresuscitation of a burn patient can lead to adownward spiral of unnecessary complications, includ-ing hypovolemic shock, renal failure, and the conversionof partial-thickness wounds to full-thickness wounds9,10.A patient with both a large, deep burn and a profoundinhalation injury, or a patient in whom resuscitation hasbeen delayed, may require significantly more fluid thanpredicted by the Parkland formula to maintain MAPand UOP11. In addition, in elderly patients, more fluid isrequired to resuscitate the same burn size than expected

to avoid hypovolemia12

, and the reason is likely to be thedecreased skin turgor which decreases the resistance tofluid accumulation or edema production.

Overresuscitation of a burn can also lead to poten-tially deleterious effects, including compartment syn-dromes involving the extremity or abdomen, pulmonaryedema, congestive heart failure, acute respiratory dis-tress syndrome, prolonged periods of ventilation, andincreased mortality10. These elderly patients may haveunderlying disease, lower cardiac output and impairedrenal function, and may, therefore, be less tolerant of

International Journal of Gerontology | September 2008| Vol 2 | No 392

■ ■ S.B. Huang et al

Table 1. Common fluid resuscitation formulae

Formula Description

Parkland Lactated Ringer’s 4mL/kg/% burn; first half given over the first 8 hours, half given over the next16 hours, then colloid 0.5mL/kg/% burn plus 5% dextrose in water 2,000 mL given over thesecond 24 hours

Brooke Lactated Ringer’s 2mL/kg/% burn, plus colloid 0.5mL/kg/% burn, administered simultaneouslyWarden Hypertonic saline 250mEq/L, given to maintain a urine output of 30mL/hr; lactated Ringer’s

with 50mEq NaHCO3; then lactated Ringer’s as needed to maintain target urine outputDemling Dextran 40 in saline at 2mL/kg/hr, then lactated Ringer’s as needed to maintain target urine outputAmerican Burn 2–4 mL/kg/% burn; the first half given over the first 8 hours, half given over the next 16 hoursAssociation formula

8/13/2019 1-s2.0-S1873959808700449-main


fluid overload. Thus, infusion of large crystalloid vol-umes should be done with extreme care in elderlypatients.

According to the study of Hagstrom et al.7 in 2003,there were substantial numbers of burn patients whowere inappropriately fluid resuscitated. Only 23% of

patients fell within the accepted range using theAmerican Burn Association formula. They even foundthat 33% of the patients had a TBSA with a more than50% discrepancy between the burn unit and emer-gency department calculations7.

Fluid formulae are merely guidelines and should beadjusted according to the patient’s overall conditionsand comorbidity, especially in elderly burn patients.Continuous monitoring and reliance on objective clin-ical outcomes must dictate the patient management. Infact, relying on fluid formulae alone can lead to insuffi-

cient resuscitation, especially in patients with excessivelydeep burns with muscle necrosis, inhalation injury anddelay in resuscitation13. Early invasive hemodynamicmonitoring, such as central venous pressure monitoring,arterial thermodilution 14 and use of a continuous car-diac output monitor, may be beneficial for the manage-ment of elderly patients with premorbid status or severeburns. With assistance of these novel invasive monitor-ing instruments, the participating clinician might havea more accurate judgment in continuous fluid admin-istration, and more precise determination for the needof additional vasopressors to support the circulation15.

Wound Management for Elderly BurnPatients

Meticulous burn wound care is extremely importantfor optimal prognosis, especially in elderly patients. Onconsideration of significant changes in the skin agingprocess, decreased epidermal turnover, decreased skin

appendages, thinning of the dermis, decreased der-mal vasculature, decreased collagen and matrix anddecreased fibroblasts and macrophages may accountfor decreases in the healing rate of a partial-thicknessburn16–18.

Aggressive, early excision (24–72 hours post-burn)of deeply burned tissues and early skin grafting providesa greater likelihood of a return of function and decreasein infections and shorter hospital stay19, although sur-vival has not always been improved for these patients20.A conservative approach for surgical intervention is not

warranted. However, thinner skin grafts are necessarybecause of the thinner skin, and a longer healing timeis expected21,22.

Pain control is often a forgotten topic in the manage-ment of burn wound care. In consideration of the eleva-tion of deleterious catecholamine levels associated with

pain, it is paramount to provide adequate and properpain control and/or sedation. The geriatric burn patientis often undertreated for pain. The most likely reasonsmay be due to the prevalent misconception of havingless pain with age and the consideration of decreasedclearance of prescribed analgesics by clinicians23.

Inhalation Injury in Elderly Burn Patients

Associated inhalation injury, present in approximately

one-third of burn patients treated at burn centers, mustbe taken into consideration. It is often suggested bysinged nasal hairs, fire in a closed space, carbonaceoussputum, or a carboxyhemoglobin level> 15%. A num-ber of studies have demonstrated an increased inci-dence of nosocomial infection, length of stay and costof hospital care among burn patients who sustainedinhalation injury24. Inhalation injury increases mortal-ity by a maximum of 20% in relation to one’s age andthe extent of the burn25.

Inhalation injury tends to be more prevalent in eld-erly patients26. It is probably because they are gener-ally less mobile and lack a protective mechanism fromstructural fires compared with the younger group. Thepresence of inhalation injury, burn size and age aresignificant independent determinants of mortality fol-lowing burn injury, and inhalation injury is the mostsignificant predictor of mortality (Table 2)27. Therefore,inhalation injury is an important comorbidity factorin geriatric patients resulting in more dismal prognosis.The same aggressive approach as used for inhalation

injury in the younger patient applies to the elderly,


■ ■Management of Elderly Burn Patients

Table 2. Independent predictors of mortality in the study of Suzuki et al. 27

Odds ratio (95% confidenceinterval)

Inhalation injury 2.58 (2.03–3.29)Full-thickness burn size 1.10 (1.09–1.11)Partial-thickness burn size 1.06 (1.06–1.07)Age 1.05 (1.05–1.06)

8/13/2019 1-s2.0-S1873959808700449-main


but keeping a lower threshold of early ventilator sup-port due to decreased lung reserve and earlier fatiguemay be advisable.

Nutritional Support of Elderly Burn Patients

Given the pronounced metabolic response elicited byextensive burn injuries, extensive nutritional supportto meet the increased energy expenditure is essentialfor the survival of burn patients. Early continuousinternal nutritional support via nasogastric tube feed-ing is the preferred supplementary route for providingthe extensive calorie requirement to the acutelyinjured burn patient, and it statistically significantlydiminishes the frequency of sepsis complications28,29

and is effective in the prevention of stress hemorrhage

in the upper gastrointestinal tract of these patients30.The feeding diet is formulated on basal energy expen-diture with incremental energy input determined bybody weight and burn size.

The presence of malnutrition and involuntaryweight loss has been shown to be a major risk factorfor increased infections, impaired wound healing, andmortality. Protein-energy malnutrition and involuntaryweight loss are a common problem in the elderly pop-ulation31. The goal of nutritional support must not bemaintenance alone but rather replacement therapy,especially of micronutrients, as preexisting deficiencystates are common22.

Prognosis of Elderly Burn Patients

Percentage TBSA burn, inhalation injury and age all havebeen shown to be independent predictors of mortalityand prognosis in burn victims2,32–35. However, the recentstudies of Pomahac et al. revealed that modern burn

care allows survival in many patients aged over 80years with less than 60% TBSA burns, without signifi-cant other comorbidities36.

Krob et al., in 1991, showed that general traumascores perform poorly when used to attempt to prognos-ticate burn injuries37. There are many scoring systemsdesigned for quantification of severity of burns andprediction of mortality of burn patients. TBSA and burnindex (burn size of third degree× 1 + burn size of sec-ond degree × 1/2) are very easy to use, but they evalu-ate only the severity of burns38. The prediction of burn

mortality using the Baux Score (age+ %TBSA, e.g., 50years + 20% burn= 70% mortality) is obviously quitevariable depending on associated medical factors, andit does not provide reliable correlations with actual mor-tality in very old patients39–41. The predictive formula ofRyan et al.2 applies three objective clinical criteria at

the time of admission, including age over 60 years,more than 40% of TBSA, and inhalation injury. Theirsimple method predicts 0.3%, 3%, 33% or approxi-mately 90% mortality, depending on whether zero,one, two or three risk factors are present, respec-tively2. However, the limitations of the formula ofRyan et al. become apparent when a 100% TBSA burnvictim without the other two factors (age, inhalation)would have only a 3% risk of death2,3. The PrognosticBurn Index, which is calculated by summation of burnindex and age, is a convenient index of prognosis, but

also has limitations in elderly patients and in patientswith severe underlying illness42.

The Abbreviated Burn Severity Index (ABSI), pub-lished by Tobiasen et al. in 1982, is a more recent indexbased on five variables: age, sex, full-thickness burn,TBSA burned, and inhalation injury (Tables 3 and 4)43.



Table 3. Abbreviated Burn Severity Index

Parameter Score % TBSA Score

Male 0 1–10 1

Female 1 11–20 2

Age group 21–30 30–20 years 1 31–40 421–40 years 2 41–50 541–60 years 3 51–60 661–80 years 4 61–70 7> 80 years 5 71–80 8

Inhalation injury 1 81–90 9

Full-thickness burn 1 91–100 10

TBSA= total body surface area.

Table 4. Predicted mortality with Abbreviated Burn Severity Index

ABSI Mortality

2–3 < 1%4–5 2%6–7 10–20%8–9 30–50%10–11 60–80%

8/13/2019 1-s2.0-S1873959808700449-main


ABSI is more accurate and specific in describing out-comes for the victims of burn injury, and it was alsofound to be a good indicator of survival when used in astudy of burns in octogenarians, although the ABSI doesnot take coexisting morbid conditions into account.Concerning the vulnerability of elderly burn patients,

ABSI seems to be superior in predicting outcome in thegeriatric population following thermal injury39,43,44.

Rehabilitation of Elderly Burn Patients

The subsequent problem of secondary scarring and con-strictive wounds are encountered after the acute stage.Significant degradation in quality of life and social func-tionality would be expected. The long-term disabilityis much greater in elderly burn patients. Approximately

50% of elderly patients with a major burn return to ahome environment within the first year comparedwith nearly 90% of younger adults45–47. Hence, theimportance of aggressive rehabilitation to avoid earlyloss of function or strength cannot be overempha-sized. The geriatric patient is capable of resistance exer-cise for muscle strength and should not be managedconservatively48.

Prevention Strategies for Elderly Burn Patients

The best management for burn injury is prevention.Given that the majority of these injuries are preventa-ble, it is important to focus on effective burn preven-tion strategies in addition to improved burn treatment.Approximately 30% of elderly patients are the victimsof self-neglect, and injuries are, therefore, preventable.In addition, at least 10% are the victims of elder abuse49.Burn prevention campaigns and educational programsfor the elderly should focus on reducing flame and

scald burns that occur in the home, preferably usingtelevision, news and poster media50. Optimal and safeliving environments for a growing older populationare necessary for injury prevention.

Conclusion

Given the increasing population of people over theage of 65, geriatric thermal injury still remains a chal-lenge from clinical, rehabilitative, social and ethical

perspectives. Recent literature reveals the present lim-itations for improvement of survival rates and progno-sis in elderly burn patients, despite advances in the careof patients with major burns. Concerning the uniquephysiologic and metabolic changes in geriatric patients,it is imperative that a well organized, protocol-driven

approach to provide for proper medical care be con-sidered. Furthermore, ongoing effective health pre-vention programs also necessitate focusing on bothprevention and damage limitation with the aim of areduction in burn events.

References

1. Chien WC, Pai L, Chiu WT. [The temporal trend and dis-tribution of burns in Taiwan.] Taiwan J Public Health,

2005; 24: 43–51. [In Chinese]2. Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL,

Cassem EH, Tompkins RG. Objective estimates of the prob-ability of death from burn injuries. N Engl J Med 1998;338: 362–6.

3. Muller MJ, Pegg SP, Rule MR. Determinants of deathfollowing burn injury. Br J Surg 2001; 88: 583–7.

4. Health and Vital Statistics, 2002, Republic of China.Taiwan: Department of Health, December 2003. [InChinese]

5. Hammond J, Ward CG. Burns in octogenarians. South

Med J 1991; 84: 1316–9.6. Anous MM, Heimbach DM. Causes of death and predic-tors in burned patients more than 60 years of age. J Trauma 1986; 26: 135–9.

7. Hagstrom M, Wirth GA, Evans GR, Ikeda CJ. A review ofemergency department fluid resuscitation of burnpatients transferred to a regional, verified burn center.Ann Plast Surg 2003; 51: 173–6.

8. Klein MB, Hayden D, Elson C, Nathens AB, Gamelli RL,Gibran NS, et al. The association between fluid adminis-tration and outcome following major burn: a multicen-ter study. Ann Surg 2007; 245: 622–8.

9. Baxter CR, Marvin JA, Curreri PW. Fluid and electrolytetherapy of burn shock. Heart Lung 1973; 2: 707–13.

10. Monafo WW, Halverson JD, Schechtman K. The role ofconcentrated sodium solutions in the resuscitation ofpatients with severe burns. Surgery 1984; 95: 129–35.

11. Navar PD, Saffle JR, Warden GD. Effect of inhalationinjury on fluid resuscitation requirements after thermalinjury. Am J Surg 1985; 150: 716–20.

12. Bowser-Wallace BH, Cone JB, Caldwell FT Jr. Hypertoniclactated saline resuscitation of severely burned patientsover 60 years of age. J Trauma 1985; 25: 22–6.



8/13/2019 1-s2.0-S1873959808700449-main


13. Baxter CR, Marvin JA, Curreri PW. Early management ofthermal burns. Postgrad Med 1974; 55: 131–9.

14. Holm C, Melcer B, Horbrand F, Henckel vonDonnersmarck G, Muhlbauer W. Arterial thermodilu-tion: an alternative to pulmonary artery catheter forcardiac output assessment in burn patients. Burns2001; 27: 161–6.

15. Reid RD, Jayamaha J. The use of a cardiac output moni-tor to guide the initial fluid resuscitation in a patient withburns. Emerg Med J 2007; 24: e32.

16. Goodson WH 3rd, Hunt TK. Wound healing and aging. J Invest Dermatol 1979; 73: 88–91.

17. Jacobson RG, Flowers FP. Skin changes with aging anddisease. Wound Repair Regen 1996; 4: 311–5.

18. Kurban RS, Bhawan J. Histologic changes in skin associ-ated with aging. J Dermatol Surg Oncol 1990; 16: 908–14.

19. Kara M, Peters WJ, Douglas LG, Morris SF. An early surgi-cal approach to burns in the elderly. J Trauma 1990; 30:

430–220. Deitch EA. A policy of early excision and grafting in theelderly burn patients shortens the hospital stay andimproves the survival. Burns Incl Therm Inj 1985; 12:109–14.

21. Bull JP, Squire JR. A study of mortality in a burns unit:standards for the evaluation of alternative methods oftreatment. Ann Surg 1949; 130: 160–73.

22. Demling RH. Care of geriatric patients. In: Herndon DN,ed. Total Burn Care, 2nd edition. London: WB Saunders,2001; 439–41.

23. Honari S, Patterson DR, Gibbons J, Martin-Herz SP,

Mann R, Gibran NS, et al. Comparison of pain controlmedication in three age groups of elderly patients. J BurnCare Rehabil 1997; 18: 500–4.

24. Rue LW 3rd, Cioffi WG, Mason AD, McManus WF, Pruitt BA Jr. Improved survival of burned patients with inhalationinjury. Arch Surg 1993; 128: 772–8.

25. Pruitt BA Jr, Cioffi WG, Shimazu T, Ikeuchi H, Mason AD Jr.Evaluation and management of patients with inhalationinjury. J Trauma 1990; 30 (12 Suppl): S63–8.

26. Smith DL, Cairns BA, Ramadan F, Dalston JS, Fakhry SM,Rutledge R, et al. Effect of inhalation injury, burn size,

and age on mortality: a study of 1447 consecutive burnpatients. J Trauma 1994; 37: 655–9.27. Suzuki M, Aikawa N, Kobayashi K, Higuchi R. Prognostic

implications of inhalation injury in burn patients inTokyo. Burns 2005; 31: 331–6.

28. Gudaviciene D, Rimdeika R, Adamonis K. Influence ofenteral nutrition on the frequency of complications incase of major burns. Medicina (Kaunas) 2004; 40: 957–61.

29. Pereira JL, Gómez-Cia T, Garrido M, Parejo J, Jódar E,Serrano P, et al. [Decrease of the incidence of sepsis syn-drome after early enteral nutrition of patients with severeburns.] Nutr Hosp 1996; 11: 274–8. [In Spanish]

30. Raff T, Germann G, Hartmann B. The value of earlyenteral nutrition in the prophylaxis of stress ulcerationin the severely burned patient. Burns 1997; 23:313–8.

31. Demling RH. The incidence and impact of pre-existingprotein energy malnutrition on outcome in the elderlyburn patient population. J Burn Care Rehabil 2005; 26:

94–100.32. Sheridan RL, Hinson MI, Liang MH, Nackel AF, Schoenfeld

DA, Ryan CM, et al. Long-term outcome of childrensurviving massive burns. JAMA 2000; 283: 69–73.

33. Zawacki BE, Azen SP, Imbus SH, Chang YT. Multifactorialprobit analysis of mortality in burned patients. Ann Surg1979; 189: 1–5.

34. Tredget EE, Shankowsky HA, Taerum TV, Moysa GL,Alton JD. The role of inhalation injury in burn trauma.Ann Surg 1990; 212: 720 –7.

35. Saffle JR, Davis B, Williams P. Recent outcomes in the

treatment of burn injury in the United States: a reportfrom the American Burn Association patient registry. J Burn Care Rehabil 1995; 16: 219–32, discussion 288–9.

36. Pomahac B, Matros E, Semel M, Chan RK, Rogers SO,Demling R, et al. Predictors of survival and length of stayin burn patients older than 80 years of age: does agereally matter? J Burn Care Res 2006; 27: 265–9.

37. Krob MJ, D’Amico FJ, Ross DL. Do trauma scores accu-rately predict outcomes for patients with burns? J BurnCare Rehabil 1991; 12: 560–3.

38. Tanaka Y, Shimizu M, Hirabayashi H. Acute physiology,age, and chronic health evaluation (APACHE) III score is

an alternative efficient predictor of mortality in burnpatients. Burns 2007; 33: 316–20.

39. Wibbenmeyer LA, Amelon MJ, Morgan LJ, Robinson BK,Chang PX, Lewis R 2nd, et al. Predicting survival in anelderly burn patient population. Burns 2001; 27: 583–90.

40. Pereira C, Murphy K, Herndon D. Outcome measures inburn care. Is mortality dead? Burns 2004; 30: 761–71.

41. Clark DE, Dainiak CN, Reeder S. Decreasing incidence ofburn injury in a rural state. Inj Prev 2000; 6: 259–62.

42. Lionelli GT, Pickus EJ, Beckum OK, Decoursey RL,Korentager RA. A three decade analysis of factors affect-

ing burn mortality in the elderly. Burns 2005; 31: 958–63.43. Tobiasen J, Hiebert JH, Edlich RF. Prediction of burnmortality. Surg Gynecol Obstet 1982; 154: 711–4.

44. Roi LD, Flora JD Jr, Davis TM, Wolfe RA. Two new burnseverity indices. J Trauma 1983; 23: 1023–9.

45. Kravitz M, Elliott S, Weissman M, Saffle JR, Warden GD.Thermal injury in the elderly: incidence and cause. J BurnCare Rehabil 1985; 6: 487–9.

46. Rossignol AM, Locke JA, Boyle CM, Burke JF. Consumerproducts and hospitalized burn injuries among elderlyMassachusetts residents. J Am Geriatr Soc 1985; 33:768–72.



8/13/2019 1-s2.0-S1873959808700449-main


47. Larson CM, Soffle JR, Sullivan J. Lifestyle adjustments inelderly patients after burn injury. J Burn Care Rehabil1992; 13: 48–52.

48. Frontera WR, Meredith CN, O’Reilly KP, Knuttgen HG,Evans WJ. Strength conditioning in older men: skeletalmuscle hypertrophy and improved function. J ApplPhysiol 1988; 64: 1038–44.

49. Bird PE, Harrington DT, Barillo DJ, McSweeney A,Shirani KZ, Goodwin CW. Elder abuse: a call to action. J Burn Care Rehabil 1998; 19: 522–7.

50. Redlick F, Cooke A, Gomez M, Banfield J, Cartotto RC,Fish JS. A survey of risk factors for burns in the elderlyand prevention strategies. J Burn Care Rehabil 2002; 23:351–6.



1-s2.0-S1873959808700449-main

Documents

Transcript of 1-s2.0-S1873959808700449-main