The use of NexoBrid™ enzymatic debridement and coagulation abnormalities.

OBJECTIVES: Current evidence on how the use of bromelain-based enzymatic debridement techniques (NexoBrid™) affect patient coagulation is limited. A single patient case report [1] suggests that a patient with 15% total body surface area (TBSA) burn developed decreased coagulation activity following debridement with NexoBrid™ enzymatic debridement (ED). Regional Burns Centres in the United Kingdom may be reluctant to use ED, particularly in larger burns, citing concerns regarding coagulation. At our centre we have routinely used ED on deep partial thickness burns since 2017 including on patients with burns over 15% TBSA. This study aims to investigate whether there is a significant disruption in coagulation in patients undergoing ED with burns > 15% TBSA or admitted to intensive care compared to the standard of care (SOC) which is surgical debridement in theatre. METHODS: This single-centre retrospective study includes all patients with a burn treated with ED at Pinderfields General Hospital Regional Burns Centre intensive care unit (ITU) from 2017 to 2020. Patients were matched to those treated with SOC at the same centre by age, % TBSA burn and presence of inhalational injury. These parameters correlate with the Baux score [9]. Percentage of burn debrided was matched as closely as possible, with coagulation profiles and platelet count taken the day before, the day of and three days following surgery. RESULTS: Thirty-one patients were treated with ED in the intensive care unit between 2017 and 2020. Four patients were excluded due to insufficient records and one patient was anti-coagulated. Twenty-six patients were included and matched as described above. Average age of patients receiving ED was 44 years, the same in the matched group. Average TBSA burn is 35.5% (35.8% in matched group). No statistically significant difference in coagulation was seen between patients undergoing ED compared to SOC when considering prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count. Both groups slightly breached the upper limit of normal on day 2 post ED and SOC. There was a slight breach of the lower limit of the average platelet count on day 2 post-ED which was neither statistically nor clinically significant. CONCLUSIONS: Large burns are associated with coagulation abnormalities, therefore isolating a single variable in this cohort is challenging. However, this study found no significant change following ED use when compared to SOC and therefore no convincing evidence that ED is associated with coagulation abnormalities. This study represents one of the largest focusing on coagulation abnormalities following the use of ED, as the current literature is limited. Our study suggests that concerns regarding coagulation abnormalities should not prevent patients with large, deep partial thickness burns or full thickness burns being treated with ED.

Survey of plastic surgery trainee attitudes to a career as a burns surgeon: A potential workforce dilemma.

AIM AND METHOD: The aim of this study was to gain insight into potential pitfalls in workforce planning for future consultant burns surgeons. An anonymous online survey was sent to current plastic surgery registrars in the UK to assess their subspecialty career choices, the perceived barriers to a career in burns surgery and possible solutions to these. RESULTS: The response rate was 33%. Of 44 respondents, burns surgery was the primary subspecialty of choice for 2% (n = 1) and the secondary choice for 9% (n = 4). Reasons given for not selecting burns surgery included a lack of exposure to the subspecialty, a perceived narrow scope of clinical practice and a concern about the potential negative impact on personal lifestyle. DISCUSSION AND CONCLUSION: Our results may be extrapolated to demonstrate a potential shortfall in the workforce for burns surgery in the future. To address the perceived barriers highlighted by trainees, a coordinated response at a national and international level is most likely to be successful through the cooperation of burns associations. Possible solutions include increasing burns subspecialty exposure during training, incorporating experience in intensive care into surgical training, and highlighting the numerous research opportunities in burns surgery.

Contact Burns From Central Heating Radiators in Adults-An Increasing Problem in an Aging Population.

The primary method of heating residential dwellings in the developed world is through central heating radiators. These appliances are a major risk factor for contact burns, especially in individuals at the extremes of age. This article presents our findings of radiator contact burns in adults treated at a regional burns service during a 6-year period. We identified a total of 116 patients and 60% were male. The mean age was 58 (range 16-97), 71% had at least one comorbidity, with a mean of 1.88 comorbidities for each patient (range 0-8). The mean TBSA was 1.7% (range 0.1-8). Thirty-three patients (26%) required at least one operation with the average number of procedures being 1.45 (range 1-4). The mean length of stay was 16 days (range 0-98) compared to 7.5 days for all admitted patients across the same period. Four patients died within 30 days of their injury, 7 within 90 days, and 16 had died within 1 year of their injury. There have been previous smaller studies looking at contact burns from radiators in both adult and pediatric populations, demonstrating a bi-modal distribution at the extremes of age. This study is the largest of its kind looking specifically at an adult population and demonstrates that these injuries tend to occur in a population with a number of other comorbidities. These patients often required prolonged hospital care.

Burn injury from filling balloons with nitrous oxide.

We present the case of a female teenager who sustained nitrous oxide burns to the medial aspect of both thighs from contact with a nitrous oxide canister being used to fill balloons. There was a delay in presentation as the injury was not initially recognised. These burns were initially assessed as being superficial partial-thickness burns but took a prolonged time to heal despite regular wound care. This was complicated by a lack of adherence to recommended treatment for much of the patient care as well as the patient testing positive for COVID-19 during their management, which prevented surgery and significantly extended time to healing. While small numbers of similar cases have been previously described this is the first reported case outside of the Netherlands and in a child. Being aware of such cases ensures early referral to specialist burn care for appropriate management to give patients the best possible outcome.

The Impact of COVID-19 on Adult Burn Management in the United Kingdom: A Regional Center Experience.

In this study, we aim to quantify the impact of COVID-19 on burns provision at an adult regional burn center. Two cohorts of patients were identified for comparison: one during the beginning of the COVID-19 lockdown in April 2020 and a comparator cohort in April 2019. There was a 30% decrease in the incidence of adult burns in 2020. The mean total body surface area (TBSA) was 1.8% and 4.3% in 2019 and 2020, respectively. Scald injuries were the commonest mechanism of burns in both cohorts. Depth of burns was deeper in 2019, with 17.6% of patients presenting with deep burns, compared with 9.6% in 2020. Eight percent of patients in 2019 required theater compared with zero patients in 2020. A similar percentage of patients were admitted in both cohorts. In 2019, admitted patients had an average inpatient stay of 0.57 days per TBSA. In 2020, the average stay per TBSA in all patients was 0.6 days and 1.5 days in survivors. In the lockdown period, 54% of patients were followed up by telemedicine. This difficult period has taught us how important a functioning healthcare system is and how we can be better prepared in the future.

Posterior ischemic optic neuropathy following a major burn injury and review of the literature.

Posterior ischemic optic neuropathy following burns is a rare but devastating condition that can result in total bilateral visual loss. Numerous treatment modalities have been trialed, yet there is no effective therapy to delay or reverse the disease. Hence, it is imperative for burns surgeons to be aware of the potential risk factors and have a high index of suspicion right from the outset to prevent this outcome. Here, we discuss the case of a patient that developed posterior ischemic optic neuropathy subsequent to a major burn injury. We also present a literature review on optic neuropathies following burns to describe the etiology, clinical signs, and potential management.

The untold story of the scorching sun-A wake up call for sun protection.

Despite extensive warnings from health authorities regarding the dangers of direct sunlight exposure, most people still turn to sun bathing to get a golden tan. Unfortunately, that pleasant tan appearance is often lost because of over exposure to sunlight, resulting in painful red sunburns. In this paper we are reporting a case with significant sunburn injuries that required hospitalization and treatment in a burn center. Concurrently a pilot study was conducted to assess the knowledge about sun protection among the adult population and the results are discussed. The results obtained from the study revealed the lack of knowledge regarding sun protection and sun seeking behaviour among the responders. Deeper burns are rarely caused by direct sunlight exposure and are underreported in literature. Despite extensive health education and warnings, there are significant numbers of sunburn injuries reported annually. On most occasions, these are superficial and are in the form of erythema. Nonetheless, the public is unaware of the impending risks of developing deep sunburn injuries that can occur especially during protracted holiday exposures. Therefore, it is crucial to escalate public awareness and to implement preventive measures to reduce the short and long-term risks of sun exposure.

Smoking, substance abuse, psychiatric history, and burns: trends in adult patients.

Keeping in mind the historical importance of the associations among smoking, substance abuse, psychiatric history, and burns, we collected the relevant data as part of a larger research project. A retrospective casenote review was conducted using 1981, 1991, and 2001 as reference years to identify the trends in acute adult admissions. In keeping with the increase in the total number of patients, burns victims who were smokers increased in numbers. The percentage increased in 2001 from other reference years, but it was not statistically significant. The results of our study also show no significant increase in trends as far as burns causation and alcohol/psychiatric history/drug dependence is concerned, but the prevalence of these conditions in burns patients has remained persistently high compared with the general population in the past 20 years.