Outpatient and Minor Burn Treatment.

Burn injuries are common; most burn injuries may be considered minor and are suitable for outpatient management. Steps should be taken to ensure that patients managed in this way still retain access to the full burns multidisciplinary team, and that admission remains an option if complications develop or according to patient preference. Modern antimicrobial dressings, outreach nursing teams, and the use of telemedicine means that the number of patients that can be safely managed without hospital admission is likely to increase further.

Patient or Prisoner?: Acute Burn Injuries in Prisoners-The Birmingham Burns Centre Experience.

Increased risk of violence and self-harm means prisoners are a vulnerable population with complex health needs. They account for a small proportion of patients with burn injuries; however, present a unique set of challenges. This study investigates the incidence, pattern and outcomes of burn injuries in prison population. Prisoners referred from 2010 to 2021 were identified using the International Burn Injury Database (iBID). Patient demographics, burn injury characteristics and outcomes were collected. Patients were then stratified based on mechanism of injury, treatment modality (surgery/conservative), hospital admission (inpatient/outpatient), and compliance with outpatient follow-up, for subgroup analyses. Sixty-eight prisoners sustained burns during the study period, with a median age of 28.5 years and TBSA of 3%. The majority were male (98.5%) and required hospital admission (75%). Scalds were the most common injury type (77.9%) and assault the most frequent cause of burns (63.2%). Eighteen patients (26.5%) underwent a surgical procedure and there were two mortalities. Of patients for whom follow-up was planned, 22% attended no appointments, with a further 49% of prisoners missing at least one appointment. Relative to patients managed nonoperatively, prisoners undergoing surgery had a longer stay and all attended outpatient follow-up appointments. Prisoners represent a unique population with exceptional challenges. Attention should be given to protecting vulnerable patients at risk of assault, education of prison staff around burn prevention and first aid, and ensuring that prisoners are able to access burns follow-up to minimize long-term sequelae. Opportunities exist to aid this such as the adoption of telemedicine.

Short and long term mortality following massive burn injury (>50% TBSA) in a UK burns centre.

INTRODUCTION: Despite advances in burn care, large burn injuries carry significant mortality risk. Although studies examining immediate mortality are available, little data is available regarding risk after discharge from hospital. This study aimed to determine short and long term mortality rate at a UK burns centre for patients with massive burn injuries. We were particularly interested to determine whether mortality rate for self inflicted injuries was present and whether this was by suicide. METHODS: The International Burn Injury Database (iBID) was interrogated to identify patients admitted with> 50% TBSA (total body surface area) injuries from January 2009- September 2019. Documented cause of death on death certificates were viewed for patients who died. General Practitioners were contacted to determine if discharged patients were alive. Descriptive statistics were generated. RESULTS: 96 patients were identified. Mean age was 45.6 years (range 16.4-93.7) with male to female ratio of 2:1. Mean TBSA was 71.8% (range 50-99). Mortality was 71.9% and was higher in females (75.7% vs 69.8%). Overall mean revised Baux score was 130 (range 68-184). Nearly half were self-inflicted (49.0%) with higher TBSA (74.4%). Of 69 patients who died only 1 was after discharge. Coroner inquiry determined that this was caused by acute alcohol intoxication. Most of those who died did so within 60 days (91.3%), usually within 48 h (71.0%). Burn futility accounted for most deaths (71.0%) followed by multi-organ failure (14.5%). CONCLUSIONS: Large burns carry significant mortality risk. Self-inflicted large burns carry a higher mortality which may be attributed to larger TBSA. In patients surviving to discharge long term prognosis is good. Patients with self-inflicted burns seem to not make a subsequent successful suicide attempt after discharge from hospital.

Temperature management of adult burn patients in intensive care: findings from a retrospective cohort study in a tertiary centre in the United Kingdom.

INTRODUCTION: Patients with major burn injury are prone to hypothermia, potentially resulting in an increase in mortality and length of hospital stay. Our study comprehensively evaluates the practicalities of physiological thermoregulation and temperature control in the largest cohort of critically ill adult burn patients to date. MATERIAL AND METHODS: This retrospective study of routinely collected patient data from the Intensive Care Unit (ICU) of the West Midlands Burn Centre was conducted over a three-year period (2016-2019). Data were analysed to assess temperature control against local and International Society for Burn Injury (ISBI) standards. RESULTS: Thirty-one patients with significant burn injuries, requiring active critical care treatment for more than 48 hours were included (total body surface area [TBSA] mean = 42.7%, SD = 18.1%; revised Baux score [rBaux] = 99, SD = 25). The majority were male (77.29%) with an average age of 44 years (17-77 years). The patients were cared for in the ICU for a total of 15 119 hours. Hypothermia, defined as core temperature below 36.0°C, was recorded for 251 hours (2% of total stay). Only 27 patients (87%) had their temperature ≥ 36°C for more than 95% of their admission. Non-survivors were more prone to hypothermia during their stay in ICU. There was an association between rBaux score and post-opera-tive temperature, with a 0.12°C decrease per 10 points increase in rBaux score (P = 0.04). CONCLUSIONS: We have observed a high variability of temperature control between individual patients, especially in non-survivors, and have demonstrated an association between high rBaux score and poor temperature control, specifically during the postoperative period.

Incorporating multi-source feedback into a new clinically based revision course for the FRCS(Plast) exam.

BACKGROUND: Exit exams for completion of surgical training are demanding and have relatively low pass rates with many candidates requiring multiple attempts. AIM: To establish a new, clinically based exam preparation course, utilising multi-source feedback, to identify candidates at risk of failure and improve pass rates. METHODS: We describe the process of establishing a new, unique, clinically based exam preparation course incorporating multi-source feedback from examiners, patients, nurses and other trainees. We present the course results as well as the exam results for each candidate and analyse the results of the multi-source feedback. RESULTS: Nine candidates have so far successfully completed both the preparation course and the FRCS(Plast) exam. Success in the exam preparation course accurately predicts success in the FRCS(Plast) exam. Nursing staff and patients tend to give higher scores than examiners and trainees. The majority of marginal failures from the course went on to pass the exam, indicating that the course allows candidates to successfully address weaknesses identified on the course. CONCLUSION: A clinically based exam preparation course utilising multi-source feedback allows identification of candidates at risk of failing a surgical training exit exam and allows targeted training in order to maximise pass rates.

A descriptive survey of operating theatre and intensive care unit temperature management of burn patients in the United Kingdom.

BACKGROUND: Patients with major burns lose the normal thermoregulatory function of their skin. They exhibit profound changes in metabolism which aim to compensate for the heat loss associated with water loss through burnt skin. Although these changes in physiology are well documented, the optimal methods for temperature management in both the Operating Theatre and Intensive Care Unit are less clear. METHODS: We distributed a survey consisting of 19 questions to all burn units and centres in the United Kingdom with the aim of ascertaining perception of both hypo and hyperthermia, as well as methods used to manage both of these scenarios. RESULTS: In the Operating Theatre, most respondents stated that they measured core temperature (82%); either alone (33%) or in conjunction with peripheral temperature (49%). In the Intensive Care Unit, most respondents measured both core and peripheral temperature (67%), with only a small minority not measuring core temperature (13%). Taking into consideration all professional groups, patients were considered hypothermic if their body temperature was less than 36.2°C (+/-0.7°C). On average, a patient was considered hyperthermic if their body temperature was above 38.8°C (+/-0.6°C). CONCLUSION: Differences in perception between the professional groups surveyed did not reach clinical or statistical significance. In both the Operating Theatre and Intensive Care Unit, hypothermia was most often managed by increasing the ambient room temperature whereas hyperthermia was most often managed by giving paracetamol. As far as we are aware, this is the first study of the management of altered thermoregulation in major burn patients in the United Kingdom.

Sepsis in burns: a review of current practice and future therapies.

Sepsis is a major cause of death worldwide and remains the subject of much research and debate within the critical care community. Despite advances in burn prevention, treatment, and rehabilitation, sepsis remains a common cause of death in patients who have sustained a severe burn injury. The unique physical, metabolic, and physiologic changes seen after major thermal injury mean that the management of sepsis in burns poses a particular challenge and differs in many respects to the management of sepsis in the general critical care population. This article describes current issues in the prevention, diagnosis, and treatment of sepsis in burns with a review of the associated literature. In addition, we discuss possible future therapies for managing this condition.

A 1 year study of burn injuries in a British Emergency Department.

OBJECTIVES: To determine the number of patients attending an Emergency Department with burns and to establish the epidemiology, management and outcome of these cases. METHOD: A retrospective study of all patients attending an Emergency Department with a diagnosis of "burn" during 2004. RESULTS: Seven hundred and eighty-five patients presented with a diagnosis of burns, accounting for 1% of all attendances. Fifty-three percent of patients were male and most were young adults of working age. Scalds and flame injuries were the most common causes of injury. Only 30% of patients performed adequate first aid. The majority of burns were small and did not require admission to hospital. Assessment and documentation by the Emergency Department staff was found to be generally poor and this may reflect a lack of experience in managing burns. CONCLUSION: Burns remain a relatively uncommon presenting complaint in the Emergency Department, even in a hospital accepting tertiary referrals. Most injuries are minor and are managed within the department. This study suggests that there is a role for better education of less experienced staff in the management of burns. There remains a need for public education in the prevention and first aid of burns.

The safety of nanocrystalline silver dressings on burns: a study of systemic silver absorption.

INTRODUCTION: Wound dressings containing silver have been in widespread use for many years. However, there are few quantitative data on the systemic absorption of silver or whether there is associated clinical risk. OBJECTIVES: To assess systemic silver levels when Acticoat dressings containing nanocrystalline silver were used, and to determine whether increases in such levels were associated with haematological or biochemical indicators of toxicity. METHOD: A prospective, single-centre, open-label study of 30 patients with relatively small burns that required skin grafting. Serum silver levels were measured before, during and at discontinuation of the use of the Acticoat dressings, and again at 3 and 6 months following completion of treatment. RESULTS: The median total postoperative wound size was 12% of the total body surface area. The median time to maximum silver levels was 9 days. The median maximum serum silver level was 56.8 microg/l. The median serum level at 6 months was 0.8 microg/l. There were no haematological or biochemical indicators of toxicity associated with the silver absorption observed in this study. CONCLUSION: This study has confirmed our view that Acticoat products are safe for use on burns and they remain a standard part of treatment at our centre.

A prospective study of time to healing and hypertrophic scarring in paediatric burns: every day counts.

BACKGROUND: It is commonly accepted that burns taking longer than 3 weeks to heal have a much higher rate of hypertrophic scarring than those which heal more quickly. However, some of our patients develop hypertrophic scars despite healing within this 3-week period. METHODS: We performed a prospective study of 383 paediatric burns treated non-operatively at a regional burns centre over a 2-year period from May 2011 to April 2013. Scar assessment was performed by a senior burns therapist using the Vancouver Scar Scale. RESULTS: Overall rates of hypertrophic scarring were 17.2%. Time to healing was the strongest predictor of developing hypertrophic scarring, and the earliest hypertrophic scar developed in a patient who was healed after 8 days. The risk of hypertrophic scarring was multiplied by 1.138 for every additional day taken for the burn wound to heal. There was a trend towards higher rates of hypertrophic scarring in non-white skin types but this did not reach statistical significance. CONCLUSIONS: The risk of hypertrophic scarring increases with every day and, therefore, every effort should be made to get the wound healed as quickly as possible, even within the traditional 3-week period usually allowed for healing. We believe that the traditional dogma of aiming for healing within 3 weeks is overly simplistic and should be abandoned: in paediatric burns, every day counts. TRIAL REGISTRATION: Not applicable.

A simple technique for protecting exposed k wire ends.

Several techniques have been described for protecting the sharp ends of Kirschner wires intraoperatively. We describe a simple, inexpensive technique, which can be used to protect the ends of the wires both intraoperatively and postoperatively.

Long-term clinical and histological analysis of Integra dermal regeneration template.

BACKGROUND: This study looked at clinical and histological outcomes of patients treated with Integra more than 2 years earlier. Although previous studies have investigated the short-term clinical and histological results, there have been no studies to investigate longer-term changes. METHODS: Fourteen patients (23 sites) were assessed. Patients used a visual analogue scale to score characteristics of their scars. Objective evaluation of the reconstructions was carried out using the Cutometer MPA580. Punch biopsy specimens of the sites were stained and labeled immunohistochemically with S100, CD31, and CD34 antisera. RESULTS: The highest scoring category by patients was softness (median, +45 percent). The lowest score was sweating, which all patients scored 0. The median Cutometer readings ranged from 39 to 52 percent of the control values. Histological examination showed three patterns of collagen arrangement; parallel arrangement was found in over 60 percent of specimens. Elastic fibers were identified in all specimens; however, all were of abnormal morphology. The majority of specimens showed evidence of nerve fiber regeneration although confined to the mid- or lower reticular dermis. There was no regeneration of skin adnexa. CONCLUSIONS: This study showed significant improvements in patient-assessed mobility, softness, and appearance. Collagen and elastic fibrin were present in all specimens, nerve fiber regeneration was limited to the mid- or lower reticular dermis, and adnexal structures were absent. The typical wrinkled appearance of mature Integra reconstruction cannot be said to be entirely due to a lack of elastic fibers.

Air ambulance transfer of adult patients to a UK regional burns centre: Who needs to fly?

INTRODUCTION: Helicopter emergency medical services play a valuable role in the transfer of critically ill patients. This paper reviews the role of air ambulance services in the provision of regional burns care and suggests guidelines for their use. METHODS: A retrospective review of patients treated at the Midlands Adult Burns Centre over a 3-year period. RESULTS: 27 adult burns patients were transported by air ambulance during the study period. Patients were aged 19-89 years (average 41.3 years) with an estimated burn size of 5-70% TBSA. Distance travelled was 11-79 miles (average 41.2 miles). All patients were appropriately referred to the burns centre according to national referral guidelines but in 7 cases (26%) it was felt that transport by air ambulance was not clinically indicated and land transfer would have been safe and appropriate. CONCLUSION: Air ambulances offer a fast and effective means of transferring patients to a regional burns centre in selected cases. There is limited data for the beneficial effects of helicopters and survival benefit is seen only in the most severely injured patients. We suggest criteria for the use of air ambulances in burns patients in order to maximise the benefit and reduce unnecessary flights.

The use of Dermal Regeneration Template (Integra®) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura.

The reconstruction of large full-thickness scalp defects remains a challenge, particularly when dura is exposed. Various reconstructive methods have been described in the past. Dermal Regeneration Templates (DRTs) are becoming increasingly popular in the management of acute wounds as well as the reconstruction of burn scars, oncological defects and various other complex reconstructive problems. We describe a case where Integra® was successfully used together with a Vacuum-Assisted Closure (VAC) dressing to reconstruct a full-thickness scalp defect with exposed dura. Surgical technique is discussed as well as problems encountered during the case and possible solutions.

Adherence to referral criteria for burns in the emergency department.

OBJECTIVE: To audit the referral patterns of burns in an emergency department compared with national referral guidelines. METHODS: A retrospective case note audit of patients attending an emergency department with a diagnosis of "burn" in a 1-year period. RESULTS: Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well. CONCLUSION: Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.