Biobrane™ and skin staples: beware of necrotic ulceration.

Biobrane™ is a product used for temporary wound coverage post major paediatric burn wound debridement. We report two cases of necrotic ulceration associated with the use of Biobrane™ with skin staples. We suggest securing Biobrane™ with alternatives such as adhesive tapes and glue to prevent the occurrence of this adverse outcome.

Airway compromise in children with anterior neck burns: Beware the scalded child.

AIM: The aim of the study was to describe characteristics of children with anterior neck burns admitted to our Paediatric Intensive Care Unit (PICU) and to highlight potential airway complications associated with these injuries, especially in children with scalds. METHODS: Retrospective review of children with anterior neck burns requiring admission to PICU January 2004-December 2013. RESULTS: Fifty-two children with anterior neck burns were admitted; average age 6.6 years. Thirty sustained flame/explosion injuries; 22 scalds. Seventy-nine per cent were male. Mean total body surface area (TBSA) burn 21%. Forty-seven were intubated. Some primary reasons for intubation included unconsciousness, inhalational/ingestion/direct airway injury and large TBSA. Majority, however, required intubation for airway complications secondary to subcutaneous/soft tissue anterior neck oedema not associated with airway injury/ingestion/inhalational burns. The scalds subgroup mean age was 2.3 years. Eighty-two per cent were male. Mean TBSA 18%. There were no inhalational/ingestion/airway injuries. Nineteen children were intubated; average 9.3 h post-injury. Majority (63%) were intubated post-arrival in the Burn Unit, compared with flame/explosion group (32%). Primary reasons for intubation included large burns, although majority (74%) required intubation for airway complications secondary to subcutaneous and soft tissue anterior neck oedema. For the flame/explosion group this was the case in only 46%, with other primary reasons such as unconsciousness or inhalational injury being the immediate precedent. CONCLUSION: These results demonstrate that subcutaneous and soft tissue oedema secondary to anterior neck burns may contribute to airway narrowing and compromise requiring intubation. When assessing children's airways, evolving oedema should be recognised and higher observation or early intubation considered regardless of the mechanism of injury.

Minor burn management: potions and lotions.

The first aid for burns is to run cold water over the burn for 20 minutes. This is effective for up to three hours after the injury. Assess the affected body surface area using the rule of nines. Consult a burn unit if more than 5% of the total body surface area is burnt in a child or if more than 10% in an adult. Extensive or deep burns and burns to special areas, such as the hands, should be referred. Chemical or electrical burns should also be assessed by a burn unit. For minor burns, antimicrobial dressings are recommended, but oral antibiotics should be avoided unless there are signs of infection. As burns are tetanus prone, check the patient's immunisation status. Burns that become infected or are slow to heal should be discussed with a burn unit. The burn unit can also provide advice if there are uncertainties about how to manage a patient.

A population-based survey of knowledge of first aid for burns in New South Wales.

OBJECTIVE: To determine the current level of knowledge of first aid for a burn injury and sources of this knowledge among the general population of New South Wales. DESIGN, SETTING AND PARTICIPANTS: People aged 16 years or older were interviewed as part of the 2007 NSW Population Health Survey, a continuous telephone survey of NSW residents. MAIN OUTCOME MEASURE: Weighted proportion of the population with optimal first aid knowledge for burns. RESULTS: In total, 7320 respondents were asked questions related to burn injuries and first aid. Of the surveyed population, 82% reported that they would cool a burn with water, and 9% reported that they would cool the burn for the recommended 20 minutes. Few respondents reported that they would remove the patient's clothing and keep the injured person warm. The most common sources of first aid information were a first aid book (42%) and the internet (33%). Speaking a language other than English at home, and being over 65 years of age were associated with a lack of first aid knowledge. CONCLUSIONS: A minority of people living in NSW know the optimal time for cooling a burn injury and other appropriate first aid steps for burns. This study demonstrates a gap in the public's knowledge, especially among non-English speaking people and older people, and highlights the need for a clear, consistent first aid message.

Biobrane™ versus acticoat™ for the treatment of mid-dermal pediatric burns: a prospective randomized controlled pilot study.

OBJECTIVES: The management of pediatric mid-dermal burns is challenging. Anecdotal evidence suggests Biobrane™ (UDL Laboratories, Inc., Sugar Land, TX) may expedite epithelization, reducing the requirement for skin grafting. Our standard management for burns of this depth is Acticoat™ (Smith and Nephew, St. Petersburg, Fl, USA). No publications are known to compare Biobrane™ to Acticoat™ for treatment of mid-dermal burns. METHODS: A prospective, randomised controlled pilot study was conducted, comparing Biobrane™ to Acticoat™ for mid-dermal burns affecting ≥ 1% Total Body Surface Area (TBSA) in children. Mid-dermal burns were confirmed using Laser Doppler Imaging within 48 hours of injury. Participants were randomized to Biobrane™ with an Acticoat™ overlay or Acticoat™ alone. RESULTS: 10 participants were in each group. Median age and TBSA were similar; 2.0 (Biobrane™) and 1.5 years (Acticoat™), 8% (Biobrane™) and 8.5% TBSA (Acticoat™). Use of Biobrane™ had higher infection rates (6 children versus 1) (P = 0.057) and more positive wound swabs, although not significant (7 children versus 4) (P = 0.37). Healing time was shorter in the Biobrane™ group, this was not significant (19 days versus 26.5 days, P = 0.18). Median dressing changes were similar (5 versus 5.5) (P = 0.56). Skin grafting requirement was greater in the Acticoat™ group (7 versus 4 children, P = 0.37) and similar in % TBSA (1.75% TBSA). CONCLUSION: This pilot study suggests that the use of Biobrane™ for mid-dermal burns in children may be associated with increased risk of infection but appears to decrease the time to healing and therefore the need for skin grafting compared to Acticoat™ alone.

The effect of ambient lighting on Laser Doppler Imaging of a standardized cutaneous injury model.

OBJECTIVE: The aim of this study was to investigate the potential confounding effects of four different types of ambient lighting on the results of Laser Doppler Imaging (LDI) of a standardized cutaneous injury model. METHODS: After applying a mechanical stimulus to the anterior forearm of a healthy volunteer and inducing a wheal and arteriolar flare (the Triple response), we used a Laser Doppler Line Scanner (LDLS) to image the forearm under four different types of ambient lighting: light-emitting-diode (LED), compact fluorescent lighting (CFL), halogen, daylight, and darkness as a control. A spectrometer was used to measure the intensity of light energy at 785 nm, the wavelength used by the scanner for measurement under each type of ambient lighting. RESULTS: Neither the LED nor CFL bulbs emitted detectable light energy at a wavelength of 785 nm. The color-based representation of arbitrary perfusion unit (APU) values of the Triple response measured by the scanner was similar between darkness, LED, and CFL light. Daylight emitted 2 mW at 785 nm, with a slight variation tending more towards lower APU values compared to darkness. Halogen lighting emitted 6 mW of light energy at 785 nm rendering the color-based representation impossible to interpret. CONCLUSIONS: Halogen lighting and daylight have the potential to confound results of LDI of cutaneous injuries whereas LED and CFL lighting did not. Any potential sources of daylight should be reduced and halogen lighting completely covered or turned off prior to wound imaging.

Management and outcomes of children with severe burns in New South Wales: 1995-2013.

BACKGROUND: As a result of improvements in injury prevention, severe burns appear increasingly uncommon in Australian children. Such injuries continue to have devastating impacts, with major consequences for the patient, their family, treating clinicians and the caring institution. METHODS: A retrospective review was undertaken of Australian children who presented to our institution between 1995 and 2013 with burn injuries ≥30% total body surface area (TBSA). RESULTS: Ninety children were identified. Their median age was 3.9 years and 57% (n = 52) were male. Most injuries occurred at home (n = 63) due to fires (n = 49). The majority received inadequate first aid (n = 56) and 40 became hypothermic during initial resuscitation. A total of 79% were transferred from other institutions. The median TBSA burnt was 40% and the majority of burns were full thickness (n = 51). All but nine were managed in the Paediatric Intensive Care Unit with a mean initial hospital admission of 43.5 days. Two thirds of children were intubated, over half of those prior to transfer, with 26 having an inhalational injury and 33 escharotomies. Compared with estimated fluid requirements, most children were over-resuscitated by a median of 26.9 mL/kg. There were seven mortalities. Wound infections were common (n = 65) and 36 suffered sepsis. The median number of dressing changes was 13 (range 0-100), operations were six and packed cells transfused was 95.7 mL/kg. Overall, 54 developed hypertrophic scarring and 45 scar contractures that have required subsequent reconstructive surgery. CONCLUSION: Severe burn injuries in children have significant morbidity and mortality. They would appear expensive to manage and impact substantially on health care resources.

Spatial analysis of pediatric burns shows geographical clustering of burns and 'hotspots' of risk factors in New South Wales, Australia.

OBJECTIVE: Pediatric burns are a significant cause of morbidity and mortality, and it is estimated that more than 80% are preventable. Studies among adults have shown that burns risk are geographically clustered, and higher in socioeconomically-disadvantaged areas. Few studies among children have examined whether burns are geographically clustered, and if burn prevention programs are best targeted to high-risk areas. METHOD: Retrospective analyses examined the 2005-to-2014 NSW Severe Burns Injury Service data. Geospatial imaging software was used to map the relative-risk and clustering of burns by postcodes in Greater Sydney Area (GSA). Cluster analyses were conducted using Getis-Ord and Global Moran's I statistics. High- and low-risk populations and areas were examined to ascertain differences by sociodemographic characteristics, etiology and the extent of the burn. RESULTS: Scalds were the most common types of burns and boys were at greater risk than girls. There was significant clustering of burns by postcode area, with a higher relative risk of burns in western and north-western areas of Sydney. The high-risk clusters were associated with socioeconomic disadvantage, and areas of low burns risk were associated with socioeconomic advantage. In both high- and low-risk areas burns occurred more frequently in the 12-24 months and the 24-36 months age groups. The implication of this study is that pediatric burns risk clustering occurs in specific geographic regions that are associated with socioeconomic disadvantage. The results of this study provide greater insight into how pediatric populations can be targeted when devising intervention strategies, and suggest that an area-targeted approach in socioeconomically-disadvantaged areas may reduce burns risk.

A novel device to create consistent deep dermal burns in a porcine model.

We conducted this study to evaluate a novel device to create a consistent and reproducible deep partial thickness burn in a porcine model. A thermostatically controlled, heated aluminium disc device was fashioned by the Biomedical Department of our institution. Contact burns were made on the flank of two Great White pigs by applying the device heated to 92°C at intervals of 5, 10, 15 and 20 seconds to four separate test areas area of skin. Biopsies for histological analysis of burn depth were taken on day 0 at 10 minutes post burn and on day 8. Biopsies taken at day 0 revealed superficial to mid-dermal burns, with minimal dermal edema and necrosis. Those from day 8 showed mid to deep dermal edema and necrosis in all four test areas following a 20 second contact duration burn. The new contact burn device was able to create a consistent deep dermal burn after 20 seconds of contact. We anticipate that this new device could be used to investigate the development of hypertrophic scarring in a porcine model.

Clothing-related burns in New South Wales, Australia: impact of legislation on a continuing problem.

To combat the risk of nightwear burns a mandatory standard regulating the design, flammability and labelling requirements of children's nightwear was introduced in Australia in 1987. This population-based study examined the trends, characteristics and causes of clothing-related burns to inform a review of the current standard, and to facilitate the development of targeted prevention strategies. Clothing-related burns for 1998-2013 were identified from hospitalisation data for all hospitals in NSW and detailed information regarding circumstance of injury from a burn data registry. To investigate percentage annual change (PAC) in trends negative binomial regression analysis was performed. There were 541 hospitalisations for clothing-related burns, 18% were nightwear-related and 82% were for other clothing. All clothing burns decreased by an estimated 4% per year (95% CI -6.2 to -2.1). Nightwear-related burns decreased by a significantly higher rate (PAC -7.4%; 95% CI -12.5 to -2.1) than other clothing (PAC -2.5%; 95%CI -4.7 to -0.1). Exposure to open heat source (campfire/bonfire) was the most common cause, followed by cooking. Of factors known to be associated with clothing burns, accelerant use was reported in 27% of cases, cigarettes 17%, loose skirt or dress 8%, and angle grinders in 6% of cases. Hospitalisations for clothing burns are relatively uncommon in NSW and rates, particularly of nightwear burns, have decreased over the last 15 years. Strategies for continued reduction of these injuries include increasing the scope of the current clothing standard or developing new standards to include all children's clothing and adult nightwear, and increasing community awareness of the risk associated with open heat sources, accelerant use and loose clothing.

Pediatric scalp burns: hair today, gone tomorrow?

Scalp burns in the pediatric population appear relatively uncommon, with most reported cases occurring in adults secondary to electrical burns. We reviewed our experience with the management of these injuries in children. A retrospective review was conducted at our institution from March 2004 to July 2011. Scalp burns were defined as any burn crossing over the hairline into the scalp region. During the 7-year 4-month study, there were 107 scalp burns, representing 1.8% of the 6074 burns treated at our institution during that time. The cause was scald in 97, contact in 4, flame in 3, friction in 2, and chemical in 1. The majority (n = 93, 87%) appeared superficial to mid-dermal, with an average time to complete healing of 10.3 days. The remaining 14 cases (13%) were mid-dermal to full thickness, with an average time to complete healing of 50.8 days. Grafting was required in 12 cases (11%). The mean time to grafting was 4 weeks (range, 2 weeks to 2.5 months). The main complication of scalp burns was alopecia, which occurred in all grafted sites as well as in 4 patients treated conservatively. There were no other complications after grafting and no cases of graft loss. In our pediatric series, scalp burns were most commonly caused by scald injuries and were superficial to mid-dermal in depth. These generally healed rapidly but occasionally resulted in alopecia. The management of deep dermal and full-thickness scalp burns remains challenging in children, with the decision to graft often delayed.

Rural and Metropolitan Pediatric Burns in New South Wales and the Australian Capital Territory: Does Distance Make a Difference?

To determine if differences exist between children who sustain burns in rural areas and in metropolitan areas, an analysis of children presenting to the Burns Unit at The Children's Hospital at Westmead, from the January 1, 2008 to December 31, 2012 was performed. In all, 4326 children met the inclusion criteria, of which 21.2% came from rural regions. Just more than a quarter (26.0%) of rural children and 11.6% from metropolitan areas were Indigenous Australian (P < 0.0001). The average age of rural child was 4.5 years; metropolitan child was 3.9 years (P = 0.0001). Boys were more likely to sustain burns in both populations. Of the rural children, 40.8% sustained contact burns, 37.7% scald, and 12.5% flame. In contrast, 58.8% metropolitan children sustained scalds, 27.4% contact, and 4.5% flame. The home was the most common place for all burns to occur, but rural injuries commonly occurred outdoors. Burns were associated with risk-taking behavior in 15.3% rural and 8.7% metropolitan children (P < 0.0001). Nearly two thirds (65.9%) of children in both groups received adequate first aid (20 minutes of cool running water). Major burn injuries (≥10% Total BSA) occurred in 3.4% of rural and 2.1% metropolitan children (P = 0.02). Skin grafting was required in 28.3% rural and 16.3% metropolitan children (P = 0.0001). Nearly 32% of rural children required admission to the Burns Unit for >24 hours (15.9% metropolitan; P = 0.0001). Significant differences exist between burns sustained by rural and metropolitan children. This should be accounted for in burns prevention campaigns and the education of local health practitioners.

Pediatric burns research: A history or an evolution?

BACKGROUND/PURPOSE: Pediatric burns research has increasingly been recognized as a sub-specialty of its own. The aim of this study was to assess and analyze the publication patterns of the pediatric burns literature over the last six decades. METHODS: A search strategy for the Web of Science database was designed for pediatric burns publications, with output analyzed between two periods: 1945-1999 (period 1) and 2000-2013 (period 2). RESULTS: There were 1133 and 1194 publications for periods 1 (1945-1999) and 2 (2000-2013), respectively. The mean citation counts of the top 50 publications were 77 (range 45-278) and 49 (range 33-145) for periods 1 and 2, respectively. There were 26 and 20 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Of these there are two authors that have published 47 papers in both combined time-periods. There were 29 and 9 journals that have published 50% of the publications for time-period 1 and 2 respectively. In period 2, there were two burns journals that have published 37.2% of the total articles. CONCLUSIONS: Pediatric burns research has evolved from an associated, dispersed entity into a consolidated sub-specialty that has been successfully integrated into mainstream burns journals.

Pediatric burn wound impetigo after grafting.

Modern burn care techniques have reduced the risk of infection of the acute burn wound, resulting in more rapid healing and a lower incidence of graft loss. Secondary breakdown may still occur. The loss of epithelium in association with multifocal superficial abscesses and ulceration has been termed burns impetigo. This may result in considerable morbidity and require prolonged treatment. The events preceding development, the impact on the patient, and the ideal treatment appear unclear and poorly reported. In 5 years, between 2006 and 2011, 406 pediatric burns were treated with skin grafts, with 7% developing burns impetigo. Time to resolution ranged from 5 to 241 days: the mean time to complete healing was greatest with conservative management (96 days), followed by antibacterial dressings (37 days), oral antibiotics (36 days), topical steroids (16 days), and oral antibiotics in combination with topical steroids (13.5 days). Burns impetigo resulted in significant morbidity, requiring multiple visits to the treatment center and prolonged symptoms. Delay in diagnosis and treatment resulted in worse outcomes. Prompt consideration of burns impetigo should occur when postgraft patients present with suggestive clinical signs and treatment with oral antibiotics plus topical steroids should be considered.

Chemical burns in children: Aetiology and prevention.

BACKGROUND: Chemical burns account for a small proportion of total burns in children, but may require specific first aid and different modes of prevention. METHODS: A retrospective study between 2006 and 2012 of children ≤16 years treated with chemical burns at a specialist paediatric burn centre. Data were extracted from a prospectively maintained database. RESULTS: 56 episodes of chemical burns occurred during the study period. The majority (54%) occurred in boys. There were 39 (72%) patients <10 years and 17 (39%) ≥10 years. Median total body surface area burnt was 1% with nine (16%) patients requiring skin grafting. Only 24 (45%) had adequate first aid. The majority (n=46, 82%) of chemical burns occurred in the domestic setting, especially in the <10 years age group (P=0.052). Non-intentional exposure of chemicals by an unattended child accounted for half of all (n=22, 49%) chemical burns <10 years of age. Eight (47%) burns in patients ≥10 years resulted from self-harm. The most common aetiological agents were household cleaners and aerosols in the younger and older age groups respectively. CONCLUSION: Chemical burns remain infrequent but potentially preventable. These burns mainly occur in the domestic setting due to non-intentional exposure of household chemicals in children <10, and due to deliberate self-harm in children ≥10. The use of child-resistant packaging, similar to that used for medications, and improved parental practices could help decrease the incidence of burns in children <10.

Prospective, randomised controlled trial comparing Versajet™ hydrosurgery and conventional debridement of partial thickness paediatric burns.

INTRODUCTION: Conventional surgical debridement of burn wounds consists of tangential excision of eschar using a knife or dermabrasion until viable dermis or punctate bleeding occurs. The Versajet™ (Smith and Nephew, St. Petersburg, FL, USA) hydrosurgery system has also been advocated for burn wound debridement, with the suggestion that enhanced preservation of dermal tissue might reduce subsequent scarring. METHODS: A prospective randomised controlled trial was undertaken comparing Versajet™ to conventional debridement. After excluding those with facial burns, 61 children ≤16 years of age undergoing debridement and skin grafting for partial thickness burns were recruited. Adequacy of debridement was assessed by 2mm punch biopsies taken pre- and post-debridement. Surgical time, percentage graft take at day 10, time to healing, post-operative infection and scarring at 3 and 6 months were assessed. RESULTS: Thirty-one children underwent conventional debridement and 30 debridement using Versajet™. There was a significant difference in the amount of viable dermal preservation between the two groups (p=0.02), with more viable tissue lost in the conventional group (median 325 µm) versus the Versajet™ group (median 35 µm). There was no significant difference between graft take at day 10 (p=0.9), post-operative wound infection (p=0.5), duration of surgery (p=0.6) or time to healing after grafting (p=0.6). Despite better dermal preservation in the Versajet™ group, there was no significant difference between scarring at 3 or 6 months (p=1.0, 0.1). CONCLUSIONS: These findings suggest that Versajet™ hydrosurgery appears a more precise method of burn wound debridement. Although dermal preservation may be a factor in reducing subsequent hypertrophic scarring, there were no significant differences found between scarring at 3 or 6 months after-injury.

An assessment of early Child Life Therapy pain and anxiety management: A prospective randomised controlled trial.

INTRODUCTION: Burns remain extremely painful and distressing in young children. The consequences of poorly managed pain and anxiety can be life-long. Whilst Child Life Therapy (CLT) has been shown to be effective in many situations, few studies have looked at the effectiveness of CLT in regard to reducing pain and anxiety in children undergoing burn dressing changes. METHODS: A prospective, randomised controlled trial was conducted, comparing CLT versus standard care in relation to pain and anxiety scores of children undergoing their initial burn dressing change. Pain and anxiety were assessed by an independent observer and questionnaires completed by the child, parent/caregiver and nursing staff. RESULTS: 50 subjects were recruited in each treatment group; median age 2.3 years (CLT) and 2.2 years (standard care). The median total body surface area (TBSA) burnt was 0.8% (CLT) and 0.5% (standard care). The majority were partial thickness dermal burns (88% CLT, 94% standard care). Rates of parent anxiety and pre-procedural child pain and anxiety were similar. Combined and scaled pain and anxiety scores in the CLT group were significantly less than in the standard treatment group (p=0.03). Whilst pain was significantly better in the CLT group (p=0.02), fear scores, wound outcomes and the need for skin grafting were not statistically different in either group. CONCLUSIONS: The presence of a Child Life Therapist, with their ability to adapt to the environment, the child and their family, significantly reduced the experience of pain during paediatric burn dressings.

Scald burns in children aged 14 and younger in Australia and New Zealand­an analysis based on the Burn Registry of Australia and New Zealand (BRANZ).

INTRODUCTION: Scalds are a common injury in children and a frequent reason for hospitalisation despite being a preventable injury. METHODS: This retrospective two year study reports data from 730 children aged 14 years or younger who sustained a scald between 2009 and 2010 and were admitted to a burns centre in Australia or New Zealand. Data were extracted from the Burn Registry of Australia and New Zealand (BRANZ), which included data from 13 burns centres in Australia and New Zealand. RESULTS: Scald injury contributed 56% (95% CI 53-59%) of all pediatric burns. There were two high risk groups; male toddlers age one to two, contributing 34% (95% CI 31-38%) of all scalds, and indigenous children who were over 3 times more likely to experience a scald requiring admission to a burns unit than their non-indigenous peers. First aid cooling by non-professionals was initiated in 89% (95% CI 86-91%) of cases but only 20% (95% CI 16-23%) performed it as recommended. CONCLUSION: This study highlights that effective burn first aid reduces hospital stay and reinforces the need to encourage, carers and bystanders to deliver effective first aid and the importance of targeted prevention campaigns that reduce the burden of pediatric scald burns in Australia and New Zealand.