WikiJournal Preprints/Comparison between the Lund-Browder chart and the BurnCase 3D® for consistency in estimating total body surface area burned
Yoo, K; Woo, G; Jang, T; Song, J.
Objective: Measure time required to determine total body surface area (TBSA) burned (%TBSA) using the Lund-Browder chart and BurnCase 3D®, and calculate discrepancy between the two methods' %TBSA estimates.
Methods: We asked 3 burn experts with 7 to 9 years of experience to participate in our experiment by estimating TBSA burned (%TBSA) for 26 subjects with a total of 262 photos, based on the Lund-Browder chart and the BurnCase 3D. We also measured time required for each estimation.
Results: Estimations via the Lund-Browder chart and the BurnCase 3D showed statistically significant differences for Observers 1 and 2 (p < 0.05), but not for Observer 3 (p = 0.11). Inter-observer variability was insignificant among the observers (p = 0.31). When using the BurnCase 3D, burn estimation was consistent across the 3 participants (p = 0.31), yet the time spent for each method were significantly different (p < 0.05) from when using the Lund-Browder chart and the time spent for estimation did not statistically vary (p = 0.20). Time spent on burn estimation varied when using either the Lund-Browder chart or the BurnCase 3D for all participants (p < 0.05).
Conclusion: Using the BurnCase 3D over the Lund-Browder chart produced slightly different estimations for TBSA burned but estimation results stayed stable across inspectors. Due to the small sample size however, further investigation is necessary.
Total body surface area burned (%TBSA) is the primary factor used in predicting burn patient mortality and it is the primary parameter for calculating total volume of fluid resuscitation. A variety of fluid resuscitation techniques are practiced for burn patients and they all rely on the patient’s body weight and %TBSA. This approach has the disadvantage that the calculation result depends on the clinical practitioner’s subjective measurement. Harish reported that estimation for %TBSA significantly varies among referring hospitals and burn units when identical patients were taken in. Giretzlehner et al. observed that in extreme cases estimation for %TBSA for the same patient could deviate up to 16.5% in relation to the mean value among burn specialists. which in turn either increase or decrease the volume of resuscitation fluid in the same proportion, or up to 5,280mL. Excessive or insufficient infusion amount has negative effects on treatment. Therefore, efforts have been made to address such subjective deviations. Among many tools we noted that the BurnCase 3D® is easy to adopt for most environments because it costs less than other alternatives and requires only commodity hardware to use, just a regular PC and any smartphone with a camera.
In this paper, we compare the difference of the estimation for %TBSA produced with the BurnCase 3D and the conventional Lund-Browder chart, as a preliminary study, this paper investigates pros and cons of adoption.
Material and methods
For this study, 3 burn specialists with 7, 9, and 9 years of experience in burn treatment made a review on a total of 262 pictures for 26 burn patients, who have been admitted to the Hanil General Hospital of South Korea between 2013 and 2017. In the data provided to the reviewers, we included age, sex, body weight, height, type of burn, and initial burn pictures. Those who suffered electrocution or inhalation injury without any external wound were ruled out. Additionally, cases with photos of poor quality were discarded. After consulting a statistician, the number of observer was determined to 3 in order to reduce inter-observer variation. Each of the 3 participating burn specialists produced an estimated %TBSA based on the Lund-Browder chart as well as the BurnCase 3D in sequence. Time spent on each estimation was recorded.
Statistical analysis was performed using the SAS® version 9.4 for Windows. In order to compare the results based on Lund-Browder chart and the BurnCase 3D, we performed a paired t-test. In consideration of inter-observer variability, we used repeated ANOVA measure, in which we opted for the default setting. To verify differences among the three groups, we used one-way model, in which we chose average and nested-effects for unit and effect, respectively.
We collected 262 pictures for 26 subjects (Table 1) consisting of 18 males and 7 females. The number of pictures for subjects varied from 1 to 30. The subjects were 54.2±15.8 years in age, and their body mass index was 24.6±3.4kg/m2. World Health Organization(WHO) defines 25kg/m2 and 30kg/m2 in BMI as overweight and obesity each in general. However, Korean Society for the Study of Obesity(KOSSO) and Asia-Pacific section of WHO have agreed to use lower indices of 23kg/m2 and 25kg/m2 for overweight and obesity because the prevalence of diabetes and cardiovascular diseases doubles above the 25kg/m2. With the regular WHO standard, 13 patients, or 50% of the 26, were overweight and none were in the category of obesity. With the WHO standard for Asians, then, 6 patients (23.1%) were overweight and 13 patients (50%) obese. Among them, 8 cases were caused by scalding, 7 by flame, 2 by chemical, 1 by contact, and 8 by electric burn. Out of the 26 subjects, the wounds appeared on different body parts as following: 8 cases in the head; 8 cases in the neck; 16 cases in the trunk (Ant. & Post.); 2 cases in the right buttock; 3 cases in left buttock; 4 cases in the genitalia; 10 cases in the right arm (except hand); 11 cases in the left arm (except hand); 2 cases in the right hand; 3 cases in the left hand; 8 cases in the right leg; 7 cases in the left leg; 4 cases in the right foot; 3 cases in the left foot. Only 3 cases had wounds near the anus or the perineum (Table 2). The average estimation for burn size against size of TBSA burned based on the Lund-Browder chart by each observer was: 10.5±11.2% (Observer 1), 11.5±12% (Observer 2), and 9.9±10.9%(Observer 3) (Table 3). The average of all of the observers with the Lund-Browder chart was 10.6±11.3%. On the other hand, the average %TBSA based on BurnCase 3D was: 8.2±8.3%(Observer 1), 9.1±10.9%(Observer 2), and 8.9±12%(Observer 3). The average of all of the observers with the BurnCase 3D was 8.7±10.4%.
The %TBSA difference between the two methods was calculated with a paired t-test. In statistical analysis, Observers 1 and 2 showed statistical significance (p < 0.05) whereas Observer 3 did not (p= 0.11) (Table 4). Inter-individual variation was tested with Repeated ANOVA measure and we found no statistical significance (p = 0.31). Calculational difference for the Lund-Browder chart and BurnCase 3D was tested among the observers. We found no significant difference between them (p = 0.06 in Lund-Browder chart, p = 0.46 in BurnCase 3D) (Table 3).
|Table 1 | Basic characteristic about subjects [click to expand]|
|Table 2 | Wound areas (burn) of the 26 subjects [click to expand]|
|Table 3 | TBSA results of the observers (%) [click to expand]|
aTBSA results using the Lund-Browder chart
bTBSA results using the BurnCase 3D
dCoefficient of variance among observers in the BurnCase 3D
|Table 4 | Intra- and Inter-observer variability between the Lund-Browder chart and BurnCase 3D [click to expand]|
The averages of elapsed time with the Lund-Browder chart were 172±174 seconds (Observer 1), 97±93 sec.(Observer 2), and 188±153 sec. (Observer 3) (Table 5), with the net average of 152±148 sec. The averages of elapsed time with the BurnCase 3D were 461±334 sec. (Observer 1), 500±563 sec. (Observer 2), and and 757±989 sec. (Observer 3), with the net average of 573±688 sec. The elapsed time difference between the two methods was also tested, and all of the Observers showed statistical difference (p < 0.05) (Table 6). This signifies that no difference exists between the observers (p = 0.20). Inter-individual variation had statistical significance for each method (p < 0.05) (Table 6).
|Table 5 | Elapsed time of the observers for assessment (in second) [click to expand]|
aElapsed time using the Lund-Browder chart
bElapsed time using the BurnCase 3D
dCoefficient of variance among observers in the BurnCase 3D
|Table 6 | Intra- and Inter-observer variability of the elapsed time between the Lund-Browder chart and BurnCase 3D [click to expand]|
Accurate estimation for %TBSA is essential in burn treatment. This value is used for patient mortality (Baux score) estimation as well as calculating the required amount of resuscitating fluid. Three methods have been established and widely used for %TBSA estimation, yet all of them have relied on practitioner’s subjective estimation. It has been even suggested that estimated %TBSA could vary depending on the physician’s burn-related experience grows. Collis et al. have reported that smaller burns tend to be overestimated while larger burns underestimated. A recent study suggested the estimation discrepancy worsens as time progresses. Such a gap is found among burn professionals and the discrepancy of burn size estimation could be as large as 16.5%, which could vary fluid used during resuscitation by as much as 5,000mL. Inadequate infusion in burn treatment may be a cause for both over-resuscitation and under-resuscitation. Over-estimation leads to excessive infusion, which may promote pulmonary complications, compartment syndrome, and increase in likelihood of escharotomy. On the other hand, under-estimation may cause acute kidney injury and/or circulatory collapse. Such negative results however, may be caused by diverse factors including pre-morbidities, burn type, preceded dehydration. Even so, inaccuracy in %TBSA estimation due to subjective observation only hinders treatment and research for burn.
We chose the BurnCase 3D to test if burn area estimation can be made less prone to subjective discrepancy. The basis for our choice is ease of adoption for most clinical environments: it does not require purchasing special hardware for data capturing or processing. It only requires a commodity smartphone with a camera and a PC to run the software. For comparison, we used the Lund-Browder chart, which produces improved accuracy over the rule of palm and the rule of nines, but it has been reported that the result may be inaccurate for obese patients. Despite this shortcoming, the Lund-Browder chart offers more practical benefits in photographic assessment.
In our study, three clinicians with 7 to 9 years of burn treatment experience participated for burn area estimation with the Lund-Browder chart and the BurnCase 3D. We identified inter-observer difference in the BurnCase 3D-based estimations. In %TBSA assessment, we found meaningful statistical differences with the two methods between two observers while difference was insignificant for one observer. This implies variance in burn expertise among the observers. All three of the observers have substantial experience of 7 to 9 years as burn surgeons. Before starting with burn estimation, all three of them were given detailed instruction on how to use the software and went through tutorial with 5 burn images, which were excluded from burn estimation for this study. Observer 3 is an author of this study and had some experience of using the software, which may explain the insignificant statistical difference. There is a possibility that in the case of Observer 3, such previous experiences could have improve the burn size estimation. In other words, the experience of using BurnCase 3D and checking the output may have enabled Observer 3 to 'calibrate' the result for when not using BurnCase 3D. This suggests that results obtained using BurnCase 3D are more positive and closer to being objective when compared with classical methods. This implies that the discrepancy of burn-size estimation could be reduced among burn specialist, medical students, and research associates if BurnCase 3D is widely used. However, we believe research on this calibration effect and the learning curve for BurnCase 3D merits additional research.
The difference of burn estimation between results based on the Lund-Browder chart and the BurnCase 3D was insignificant in Repeated ANOVA measure. This result is in line with the research by Gertzlehner et al. but we need a larger number of participants for verification. All three observers work in the same hospital. Burn estimation based on BurnCase 3D showed no difference between the observers (inter-observer variation), which agrees with the study by Parvizi et al., which reported intraclass correlation of 0.98 with BurnCase 3D. These results imply that %TBSA estimation is consistent when the BurnCase 3D is used. With the few studies around the software, it merits further research if burn estimation variance can be reliably reduced with the BurnCase 3D.
BurnCase 3D has two methods of estimating %TBSA based on patient's photos - one that involves superimposing the photo on the 3D model and the other that does not. In the non-superimposition method, the wound and the 3D model are merely displayed separately. Superimposing photos on the 3D model creates a more accurate wound representation at the cost of more estimation time by users. On the other hand, without superimposition, %TBSA estimation can be performed faster and the difference is very marked when the burn area is large. Observers spent around 2.5 minutes for burn estimation with the Lund-Browder chart and more than 9 minutes with the BurnCase 3D, and more than 10 minutes for cases when %TBSA was thought to be greater than 10%. The greater the number of burn images, the more time our observers took for estimation. For our experiment, all of the photos were superimposed, and this may have contributed to the increased estimation time for each observer. Had we provided only the non-superimposition method, their estimation time may have been reduced, however, this factor was not anticipated in the experiment designing phase. In our future work, we will adopt both methods for %TBSA estimation.
One known shortcoming of BurnCase 3D is that estimation result can be inaccurate when the wound is located where different body parts overlap, e.g., perineum or medial side in the buttock. Only 3 out of the 26 subjects had wounds near the buttock or the perineum in our experiment. In other words, the sample size too small for claiming that BurnCase 3D has a weakness in estimating burn areas around either areas because 23 of our cases were outside of either regions. Out of the 26 subjects, 5 had %TBSA greater than 20% according to the Lund-Browder chart and the remainder, 21 subjects had %TBSA less than 20%. Discussion with our statistician for post-hoc analysis has concluded that we may not know with confidence whether the two groups are different. Our future work will research with more subjects and more participants.
Despite sufficiently wide spread of EMR (electronic medical record) systems in South Korea, little work has been published on computer-aided burn size estimation. In writing this paper as a preliminary study, we hoped to trigger future research activities. We did not include statistically sufficient number of study participants or patients, however, we were able to demonstrate differences of provisional vs. computer-aided burn area estimation methods.
As a preliminary study, this paper observed some variance in %TBSA estimation among participants when using the Lund-Browder chart and when using the BurnCase 3D. In contrast, variance was statistically insignificant when the BurnCase 3D was used. One limitation of this study was that were very few subjects with TBSA 20% or above and few had burns on perineum, making our post-hoc analysis less robust for evaluating BurnCase 3D. The meaningful discrepancy in user proficiency for using BurnCase 3D among observers and weak diversity of burn areas were additional factors that could be improved in the future.
The next research would include a larger number of observers with varied proficiencies; more in-depth evaluation method for BurnCase 3D; diverse burn areas as well as specific body parts. Since accuracy of %TBSA estimation is related to prognosis, correlation of %TBSA estimation versus mortality may meaningfully contribute to future work.
We appreciate Dr. Michael Giretzlehner and the RISC Software, GmBH for offering the BurnCase 3D without any condition.
We were granted license for BurnCase 3D by Dr. Michael Giretzlehner of RISC Software GmbH, Austria, for academic research, and we did not request or receive any other form of financial or research assistance from him.
Conflict of interest
All authors declare that there is no conflict of interest.
KT Yoo has written most of the manuscript. GW Woo and TY Jang has contributed assessing data and data collection. JS Song performed the statistical analysis and its interpretation. All authors participated in the design of the study and approved the final version of the manuscript.
This study was approved by the institutional review board in the Hanil General Hospital (HIRB-2017-009).
- Osler, T.; Glance, L. G.; Hosmer, D. W. (2010). "Simplified estimates of the probability of death after burn injuries: extending and updating the baux score". The Journal of Trauma 68 (3): 690-697. doi:10.1097/TA.0b013e3181c453b3. ISSN 0022-5282. PMID 20038856.
- Leopoldo, C.; Bohanon, F. J.; Kramer, G. C. (2018). "Burn Resuscitation". In Herndon, D.N. (ed.). Total Burn Care (5th ed.). Elsevier Inc. pp. 77–86.e2. doi:10.1016/B978-0-323-47661-4.00009-5. ISBN 9780323476614.
- Harish, V.; Raymond, A. P.; Issler, A. C.; Lajevardi, S. S.; Chang, L.-Y.; Maitz, P. K. M.; Kennedy, P. (2015-02). "Accuracy of burn size estimation in patients transferred to adult Burn Units in Sydney, Australia: an audit of 698 patients". Burns: Journal of the International Society for Burn Injuries 41 (1): 91-99. doi:10.1016/j.burns.2014.05.005. PMID 24972983.
- Giretzlehner, M.; Dirnberger, J.; Owen, R.; Haller, H. L.; Lumenta, D. B.; Kamolz, L.-P. (2013). "The determination of total burn surface area: How much difference?". Burns: Journal of the International Society for Burn Injuries 39 (6): 1107-1113. doi:10.1016/j.burns.2013.01.021.
- Haller, H. L.; Dirnberger, J.; Giretzlehner, M.; Rodemund, C.; Kamolz, L. (2009). "“Understanding burns”: research project BurnCase 3D--overcome the limits of existing methods in burns documentation". Burns: Journal of the International Society for Burn Injuries 35 (3): 311-317. doi:10.1016/j.burns.2008.07.010.
- Parvizi, D.; Giretzlehner, M.; Wurzer, P.; Klein, L. Dinur; Shoham, Y.; Bohanon, F. J.; Haller, H. L.; Tuca, A. et al. (2016-03). "BurnCase 3D software validation study: Burn size measurement accuracy and inter-rater reliability". Burns: Journal of the International Society for Burn Injuries 42 (2): 329–335. doi:10.1016/j.burns.2016.01.008. ISSN 0305-4179. https://linkinghub.elsevier.com/retrieve/pii/S0305417916000115.
- Prieto, M. Felicidad; Acha, B.; Gómez-Cía, T.; Fondón, I.; Serrano, C. (2011-11). "A system for 3D representation of burns and calculation of burnt skin area". Burns: Journal of the International Society for Burn Injuries 37 (7): 1233–1240. doi:10.1016/j.burns.2011.05.018. ISSN 0305-4179. https://linkinghub.elsevier.com/retrieve/pii/S0305417911001677.
- Rashaan, Z. M.; Euser, A. M.; van Zuijlen, P. P. M.; Breederveld, R. S. (2018-06). "Three-dimensional imaging is a novel and reliable technique to measure total body surface area". Burns: Journal of the International Society for Burn Injuries 44 (4): 816–822. doi:10.1016/j.burns.2017.12.008. ISSN 0305-4179. https://linkinghub.elsevier.com/retrieve/pii/S0305417917306769.
- Bray, G. A.; Bouchard, C. (2004). Handbook of obesity (PDF) (2nd ed.). New York, Basel: Marcel Dekker Inc. ISBN 0-8247-4773-9.
- World Health Organization (2000). Obesity: Preventing and managing the global epidemic. Report on a WHO consultation on obesity. ISBN 92-4-120894-5.
- World Health Organization. Regional Office for the Western Pacific; International Diabetes Institute; International Association for the Study of Obesity; International Obesity Task Force (2000). The Asia-Pacific perspective: redefining obesity and its treatment. Health communications Australia: Melbourne. Sydney: Health Communications Australia. ISBN 0957708211.
- Rossiter, N. D.; Chapman, P.; Haywood, I. A. (1996-5). "How big is a hand?". Burns: Journal of the International Society for Burn Injuries 22 (3): 230–231. doi:10.1016/0305-4179(95)00118-2. ISSN 0305-4179. PMID 8726264. https://www.ncbi.nlm.nih.gov/pubmed/8726264.
- Knaysi, G. A.; Crikelair, G. F.; Cosman, B. (1968-6). "The rule of nines: its history and accuracy". Plastic and Reconstructive Surgery 41 (6): 560–563. doi:10.1097/00006534-196806000-00008. ISSN 0032-1052. PMID 5654897. https://www.ncbi.nlm.nih.gov/pubmed/5654897.
- Lund, C. C.; Browder, N. C. (1944). "The estimation of areas of burns". Surgery Gynecology and Obstetrics 79: 352-358.
- Wachtel, T. L.; Berry, C. C.; Wachtel, E. E.; Frank, H. A. (2000-3). "The inter-rater reliability of estimating the size of burns from various burn area chart drawings". Burns: Journal of the International Society for Burn Injuries 26 (2): 156–170. doi:10.1016/S0305-4179(99)00047-9. ISSN 0305-4179. PMID 10716359. https://www.ncbi.nlm.nih.gov/pubmed/10716359.
- Martin, Niall A.J.; Lundy, Jonathan B.; Rickard, Rory F. (2014-03). "Lack of precision of burn surface area calculation by UK Armed Forces medical personnel". Burns: Journal of the International Society for Burn Injuries 40 (2): 246–250. doi:10.1016/j.burns.2013.05.009. ISSN 0305-4179. https://linkinghub.elsevier.com/retrieve/pii/S0305417913001563.
- Collis, N.; Smith, G.; Fenton, O. M. (1999-6). "Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year retrospective study". Burns: Journal of the International Society for Burn Injuries 25 (4): 345–351. doi:10.1016/S0305-4179(99)00007-8. ISSN 0305-4179. PMID 10431984. https://www.ncbi.nlm.nih.gov/pubmed/10431984.
- Berkebile, Brenda L.; Goldfarb, I. William; Slater, Harvey (1986-09). "Comparison of Burn Size Estimates Between Prehospital Reports and Burn Center Evaluations". Journal of Burn Care & Rehabilitation 7 (5): 411–412. doi:10.1097/00004630-198609000-00007. ISSN 0273-8481. https://insights.ovid.com/crossref?an=00004630-198609000-00007.
- Voigt, Charles D.; Celis, Mario; Voigt, David W. (2018). "Care of Outpatient Burns". In Herndon, D.N. (ed.). Total Burn Care (5th ed.). Elsevier. pp. 50–57.e2. doi:10.1016/b978-0-323-47661-4.00006-x. ISBN 9780323476614.
- Herndon, David N.; Benjamin, Debra A.; Jimenez, Carlos J.; Wurzer, Paul; Branski, Ludwik K.; Norbury, William B.; Lee, Jong O.; Benjamin, Nicole C. (2017-01-01). "Accuracy of Currently Used Paper Burn Diagram vs a Three-Dimensional Computerized Model". Journal of Burn Care & Research 38 (1): e254–e260. doi:10.1097/BCR.0000000000000363. ISSN 1559-047X. https://academic.oup.com/jbcr/article/38/1/e254/4568935.
- Parvizi, D.; Kamolz, L.-P.; Giretzlehner, M.; Haller, H. L.; Trop, M.; Selig, H.; Nagele, P.; Lumenta, D. B. (2014-03). "The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: Things to keep in mind". Burns: Journal of the International Society for Burn Injuries 40 (2): 241–245. doi:10.1016/j.burns.2013.06.019. ISSN 0305-4179.