Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience.

INTRODUCTION: Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre. METHODS: We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes. RESULTS: Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort. CONCLUSIONS: The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.

St Andrew's COVID-19 Surgery Safety (StACS) study: Skin cancer.

BACKGROUND: Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19. OBJECTIVE: This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively. RESULTS: Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups. CONCLUSION: These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic. LEVEL OF EVIDENCE: II.

St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience.

BACKGROUND: The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre. METHODS: A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April-May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described. RESULTS: Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients. CONCLUSIONS: We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

Toxic epidermal necrolysis after acute burn injury.

Toxic epidermal necrolysis is a rare, potentially fatal disorder that involves large areas of skin desquamation. Patients with toxic epidermal necrolysis are frequently referred to burn centres for expert wound management and early comprehensive critical care as this has been shown to improve patient outcome and mortality. The authors describe the first report of medication-induced toxic epidermal necrolysis occurring in a patient during acute burn management in a tertiary burn care facility. The patient sustained a 17% total body surface area flame burn to her face, chest, bilateral upper limbs and bilateral lower limbs while escaping from a wildfire. She required extensive debridement and allografting to manage burn injured areas and additional areas of epidermal loss from subsequent toxic epidermal necrolysis, amounting to a total body surface area of 90%. Definitive burn wound closure was achieved using autologous split-thickness skin grafting once donor sites healed and became suitable for harvest 3 weeks after the onset of toxic epidermal necrolysis. Grafts achieved complete take and the patient was discharged home following rehabilitation..

La nécrolyse épidermique toxique est une pathologie rare potentiellement mortelle entraînant des desquamations cutanées étendues. Ces patients sont fréquemment hospitalisés dans un CTB, en raison de leur expertise des soins locaux et de la réanimation, ce qui contribue à l'amélioration du pronostic et à la baisse de la mortalité. Nous rapportons le premier cas de nécrolyse épidermique toxique liée à un médicament survenu au cours du traitement en CTB d'une patiente brûlée. Elle souffrait d'une brûlure sur 17% SCT intéressant le visage, le thorax et les 4 membres, ayant nécessité excision et greffes. Celles ­ci n'ont pu être réalisées que tardivement, en raison d'un défaut de site donneurs car la patient a développé une nécrolyse épidermique toxique sur 90% SCT ne les ayant laissé utilisables que 3 semaines plus tard. Les greffes se sont bien intégrées et la patiente a pu retourner à domicile après rééducation..

Treatment of nasal burns: analysis of 150 cases.

Nasal burns present a challenge for the plastic surgeon in terms of immediate management, choice of primary treatment and secondary reconstruction with the goals of good aesthetic and functional outcome. We present a retrospective analysis of the management of 150 patients with nasal burns treated in our center between July 2005 and July 2011. We rationalized our conservative and all surgical treatments of this subset of burns patients and organized them in a simple and structured way. The reconstructive options for most complex full thickness nasal injury is determined by the integrity of adjacent facial tissues which would always be preferred when available. Microsurgical free tissue transfer is dependent upon the fitness of the patient and the availability of unburned skin at the donor site. Secondary nasal reconstruction is based on an assessment of the residual functional and cosmetic problems. Airways narrowing from scar contracture or loss of support are managed using standard plastic surgical and rhinoplasty principles. Cosmetic refinements range from flap debulking to the importation of new tissue on to the nose. Our experience with this challenging group of patients has led us to develop a simple treatment algorithm for the management of nasal burns.

Les brûlures nasales présentent un défi pour le chirurgien plastique en terme de prise en charge immédiate, de traitement primaire ou de reconstruction avec un objectif de bon résultat esthétique et fonctionnel. Nous présentons une analyse rétrospective de 150 patients souffrant de brûlures nasales traités dans notre centre entre Juillet 2005 et Juillet 2011. Nous avons codifié nos traitements chirurgicaux d'une manière simple et structurée. Les options reconstructives dépendent de l'intégrité des tissus faciaux de voisinage qui seront toujours préférés s'ils sont disponibles. Le transfert microchirurgical libre dépend de la condition physique du patient et de la disponibilité d'une zone donneuse. Les reconstructions nasales secondaires dépendent de l'évaluation des séquelles fonctionnelles et esthétiques. Les sténoses en rapport avec le tissu cicatriciel ou la perte de support sous jacent sont soumises aux principes de la chirurgie plastique et de la rhinoplastie .Les améliorations cosmétiques vont du dégraissage des lambeaux au transfert de tissu. Notre expérience avec ce groupe de patients nous a conduit à développer un algorithme de traitement simple pour la prise en charge des brûlures nasales.

A novel approach to reconstruct a large full thickness abdominal wall defect: successful treatment with MatriDerm® and Split.

OBJECTIVE: Reconstruction of large abdominal wall defects is a challenging procedure, often contraindicated in critically ill patients, with high incidences of complications. We present a case of a patient with a large abdominal wall defect who had reconstruction with MatriDerm® (an engineered dermal template) and split thickness skin grafting (SSG) as an alternative to reconstruction with myo- or fascio-cutaneous flaps. Successful wound closure was achieved with a single technique, while providing a robust reconstruction and an interface between skin and underlying viscera, should further surgery be necessary.

The use of Biobrane® as a delivery method for cultured epithelial autograft in burn patients.

BACKGROUND: Cultured epithelial autografts (CEA) are well described in the literature and are advantageous when dealing with major burns. There have been many methods of CEA application described, however they all have their own difficulties. Here we describe a novel technique of culturing the keratinocytes in Biobrane(®). METHODS: Skin samples were taken from three patients and cultured into pre-confluent keratinocytes. These were seeded in Biobrane(®) and applied directly to the patients' wounds. RESULTS: Three patients had Biobrane(®) with seeded keratinocytes applied. The Biobrane was applied to both donor and burn wound sites, with healing times being similar to the keratinocyte sheets. CONCLUSION: The experience of the authors shows that using Biobrane(®) seeded with keratinocytes was easier to handle and quicker to produce than confluent sheets of keratinocytes, with no perceived disadvantages to the patients.

The use of a frailty scoring system for burns in the elderly.

INTRODUCTION: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival. METHOD: Data from patients with burns greater than 10% and aged over 65 years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1-7) was assigned to each patient based on the records of their admission assessment. 42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9 years (range 65-95 years) survived (S) their ITU stay and of these, 83.3% survived at 1 year. 24 (57.2%) patients, mean age 78.4 years (range 66-95 years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10-85%) (P>0.05 using T Test) or inhalational injury (p>0.05 using Z test). Using Mann-Whitney U test analysis, the frailty score between the two groups showed a significant difference at p=0.0001 (Mann-Whitney U test=78), median=3 (S) and median=5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann-Whitney U test=111, p=0.02). CONCLUSION: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients.

Prognostic scoring systems in burns: a review.

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Comfort care in burns: the Burn Modified Liverpool Care Pathway (BM-LCP).

INTRODUCTION: Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS: A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS: There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION: The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

Estimating the usage of allograft in the treatment of major burns.

AIM: To assess the amount of allograft used in the past treatment of major burns and calculate a figure to guide estimation of the quantity of allograft required to treat future patients and aid resource planning. METHODS: A retrospective observational study. Records of 143 patients treated with major burns at a regional centre, from January 2004 to November 2008 were accessed with biometric data and quantity of allograft used being recorded. This data was used to calculate an allograft index (cm² allograft used/burn surface area (cm²)) (AI) for each patient. RESULTS: 112 of the 143 patients had complete sets of data, of the 112, 89 patients survived the initial stay in hospital. For all data average AI=1.077 ± 0.090. AI varied according to burn % area with burns < 40% requiring 0.490 cm² allo/cm²burn, increasing in a logarithmic fashion (R²=0.995) for burn areas > 40%. CONCLUSIONS: The ability to estimate deceased donor skin requirements based on % body surface area affected is important in the care planning for patients with major burns. Our findings of 0.5 cm² allograft/cm² burn for injuries less than 40% TBSA, increasing to 1.82 cm² allograft/cm² burn for injuries up to 80% TBSA can be used for planning purposes for individual services and for burn disaster planning.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit.

INTRODUCTION: 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD: All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS: 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION: The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus in a regional burns unit.

Over a 16 month period, 30 individuals (19 patients, one relative and 10 members of staff) on a regional burns and plastics unit became colonised or infected with a single strain of Panton-Valentine leucocidin-producing meticillin-resistant Staphylococcus aureus (PVL-MRSA). The strain was resistant to ciprofloxacin, neomycin and gentamicin and belonged to a community-associated MRSA lineage known to be circulating in the UK. The outbreak occurred in four stages, the first being in burns outpatients, the second and third being on the burns unit itself and the final stage on a plastics ward. In spite of closing the affected unit and deep cleaning, including steam cleaning and hydrogen peroxide treatment, the outbreak continued. It was not until staff carriage was fully addressed that the outbreak was controlled.