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.

The ten-year experience of firework injuries treated at a uk regional burns & plastic surgery unit.

Fireworks are used worldwide to celebrate national, religious, cultural festivals and holidays. However the use of fireworks is associated with preventable injuries. We aim to review cases of burns and trauma caused by fireworks presenting to a regional burns and plastic surgery unit in the United Kingdom. We hope our findings will help to guide future firework-related safety practices in the UK. A retrospective review was performed of all patients presenting to our tertiary burns and plastic surgery unit with burns and/or trauma sustained from fireworks over a ten-year period from October 2004 to October 2014. A total of 93 patients were identified. Medical case notes were reviewed, patient demographics, aetiology of injury, management and patient outcomes were recorded. A cohort of 93 patients with burn injuries caused by fireworks were identified from our database. A total of 74% injuries occurred in October and November. Mechanism of injury included contact, flash, flame burns and injury secondary to blast force. Most injuries sustained were to the hands, followed by head and neck, torso, limbs and perineum in descending order of frequency. A total of 38.7% of patients required surgery for their wounds. Fireworks not only result in significant burn injuries, but also eye injuries, soft tissue defects and fractures requiring a spectrum of plastic surgical interventions. The number and severity of accidents can be minimised by raising awareness regarding safety precautions.

Les feux d'artifices (FA) sont utilisés mondialement, dans des contextes festifs variés (religieux, nationaux, culturels, locaux). Les accidents qui y sont liés sont évitables. Nous avons étudié les brûlures et les traumatismes liés aux FA se présentant dans notre CTB, espérant que ceci permettra la mise en place de mesures de prévention dans l'ensemble du Royaume Uni. Nous avons revu rétrospectivement les dossiers des 93 patients pris en charge dans notre CTB entre octobre 2004 et octobre 2014 après un accident de FA. Les données démographiques, étiologiques, de prise en charge et évolutives ont été colligées. Les ¾ des accidents étaient survenus en octobre et novembre. Les mécanismes vulnérants étaient le contact, le flash, la flamme et le blast. Les mains étaient la région la plus fréquemment touchée, suivies par ordre décroissant par la région cervico-céphalique, le torse, les membres et le périnée. Trente huit virgule sept pour cent des patients pont du être opérés. Les accidents de FA entraînent non seulement des brûlures mais aussi des atteintes oculaires, des pertes de substance cutanées et des fractures pouvant nécessiter des interventions dans un large spectre de la chirurgie reconstructrice. Le nombre et la gravité de ces accidents peut être diminués par une application accrue des mesures de précaution.

Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience.

INTRODUCTION: Stevens Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, potentially fatal desquamative disorders characterised by large areas of partial thickness skin and mucosal loss. The degree of epidermal detachment that occurs has led to SJS/TEN being described as a burn-like condition. These patients benefit from judicious critical care, early debridement and meticulous wound care. This is best undertaken within a multidisciplinary setting led by clinicians experienced in the management of massive skin loss and its sequelae. In this study, we examined the clinical outcomes of SJS/TEN overlap & TEN patients managed by our regional burns service over a 12-year period. We present our treatment model for other burn centres treating SJS/TEN patients. METHODS: A retrospective case review was performed for all patients with a clinical diagnosis of TEN or SJS/TEN overlap admitted to our paediatric and adult burns centre between June 2004 and December 2016. Patient demographics, percentage total body surface area (%TBSA), mucosal involvement, causation, severity of illness score (SCORTEN), length of stay and survival were appraised with appropriate statistical analysis performed using Graph Pad Prism 7.02 Software. RESULTS: During the study period, 42 patients (M26; F: 16) with TEN (n=32) and SJS/TEN overlap (n=10) were managed within our burns service. Mean %TBSA of cutaneous involvement was 57% (range 10-100%) and mean length of stay (LOS) was 27 days (range 1-144 days). We observed 4 deaths in our series compared to 16 predicted by SCORTEN giving a standardised mortality ratio (SMR) of 24%. CONCLUSION: Management in our burns service with an aggressive wound care protocol involving debridement of blistered epidermis and wound closure with synthetic and biological dressings seems to have produced benefits in mortality when compared to predicted outcomes.

Spectrophotometric intracutaneous analysis for the assessment of burn wounds: A service evaluation of its clinical application in 50 burn wounds.

INTRODUCTION: The assessment of burn depth can be challenging even to the experienced burn clinician. Clinical assessment is most widely used to determine burn depth. Because of this subjective nature, various imaging modalities have been invented. The use of photospectometry as a novel technique in burn wound depth analysis has been previously described but the literature is very limited. METHODOLOGY: We carried out a single blinded non-randomized comparative study of healing potential of 50 burn wounds between tissue spectrophotometry analysis versus clinical evaluation. RESULTS: ScanOSkin™ technology has an overall sensitivity of 75% and specificity of 86% in predicting healing potential of wounds. Analysis of Inter Rater Agreement (IRA) using Kappa calculations showed strengths of agreement varied from fair to moderate in perfusion and burn depth. IRA for assessing pigmentation however, was poor and this was reflected in user feedback. CONCLUSION: There is a potential role for ScanOSkin™ tissue spectrophotometric analysis in burn depth assessment. Future studies comparing several imaging modalities with ScanOSkin®, taking into account costs comparison may be useful for future health resources planning.

The burning issues of motor vehicle radiator scald injuries revisited - a fresh review and changing prevention strategies.

A preventable subgroup of burn injuries is scalds sustained from motor vehicle radiators. This study was to determine changes in trends in epidemiology of such injuries and to discuss whether current and other prevention efforts proposed previously require reinforcement. We conducted a retrospective study (February 2007-August 2015) of all motor vehicle-related burn referrals to our regional burns service. 68 cases of motor vehicle radiator burns were identified. Male to female ratio was 65:3. Mean age was 35.1 (range = 9-71). Most cases occurred in the summer months (22/68 = 32.4%). 65 cases (95.6%) involved car radiators. 66% of injuries resulted from actively removing the pressure cap of an overheated radiator in the motor vehicle. Mean total burn surface area (%TBSA) was 2.1% (range = 0.5- 11%). The depths of burn injuries were mostly superficial partial thickness. Face, chest and upper limbs were the most common sites of injury. Mean healing time was 14.2 days (range = 4-60). Following the introduction of safety measures by vehicle manufacturers, motor vehicle radiator burns in this era are mostly minor injuries and can be potentially managed conservatively as an outpatient. This contrasts with findings from previous studies over a decade ago of larger, more significant injuries requiring admission and surgery. Whilst manufacturers have installed safety measures into the design of radiator caps, our findings suggest that re-educating the public to allow a period of cooling prior to opening caps should be reinforced.

Les ébouillantements par liquide de refroidissement de voitures (LRV) sont évitables. Cette étude a pour but d'évaluer les changements épidémiologiques de ce type d'accidents et de discuter si les stratégies préventives passées et actuelles nécessitent une mise à jour. Nous avons étudié rétrospectivement tous les patients hospitalisés dans notre CTB entre février 2007 et août 2015 à la suite de brûlures en relation avec un véhicule à moteur. Parmi ceux-ci, 68 (65 hommes, 3 femmes) âgés en moyenne de 35,1 ans (9-71) s'étaient brûlés avec du LRV. La plupart des cas (22 soit 32,4%) étaient observés en été. La grande majorité (66 cas soit 95,6%) mettaient en cause le radiateur avec 2 fois sur 3 l'ouverture de celui-ci en raison d'une surchauffe. La surface brûlée était de 2,1% (0,5-11%) et les brûlures, le plus souvent superficielles (délai de guérison moyen de 14,2 jours (4-60), touchaient principalement la partie haute du corps (visage, thorax, membres supérieurs). Les systèmes de sécurité mis en place par les constructeurs ont permis d'observer des brûlures mineures guérissant spontanément après une prise en charge en externe, contrastant avec les observations précédentes de brûlures plus étendues et plus profondes, nécessitant une hospitalisation et des greffes. Cependant, une prévention passive insistant sur la nécessité de laisser refroidir le moteur avant d'essayer d'ouvrir le radiateur semble nécessaire.

Periorbital burns ­ a 6 year review of management and outcome.

INTRODUCTION: Periorbital burns are an infrequent but potentially devastating injury. This study aimed to elucidate the spectrum of such injuries presenting to a UK burns centre and the outcome achieved in the cases requiring periorbital reconstruction for the restoration of function and form. METHODS: Patients admitted to a UK regional burns centre between January 2005 and January 2011 with periorbital burns were identified from the Patient Administration System (PAS), theatre logs and the International Burns Injury database (IBID). Multiple parameters were assessed using patient notes, ITU and hospital image databases. RESULTS: Over 6 years, 167 patients with facial burns requiring surgery were treated, including 103 patients with eyelid burns. The mean burn size was 33% total body surface area. The eyelid burn depth varied; 67% superficial partial thickness, 17% deep dermal and 16% full thickness. Two patients lost complete vision in one eye, one patient underwent amniotic membrane grafting. In total 16 patients required periorbital reconstruction to maintain eye closure, with 1.8 operations on average per patient. Acute surgery was required in 11 patients, whilst late intervention (>3 months) was needed in 5, 2 patients had both acute and delayed surgery. Of the 5 late intervention patients 4 were treated with full thickness skin grafts and 1 with a Z plasty. Average time for final reconstruction with delayed surgery was 4.5 months. CONCLUSION: The goal in management of periorbital burns is preservation of vision, prevention of future complications and restoration of an acceptable aesthetic outcome. Total visual loss is thankfully rare, but early ophthalmology intervention is vital given the evidence of corneal damage as a brief therapeutic window exists.

Improvement of survival in patients with extensive burns involving the perineum with use of a faecal management system.

The purpose of this study is to assess the effectiveness of faecal management systems in improving survival of patients with extensive burns involving the perineum. All adults with burns of more than 30% total body surface area (TBSA) who were actively treated in our regional burn service between December 2008 and July 2012 were reviewed and compared to an historical cohort of 18 adult patients with similar injury involving the perineum, treated in our regional burn service between 1999 and 2001. For the last five years, faecal management systems (FMS) have been in use for patients with extensive burns involving the perineum. Sixteen patients with burns greater than 30% TBSA involving the perineal region were admitted during this period and all were managed with FMS. Four of the 16 patients (25%) managed with FMS died compared to 11 of the 18 patients (61%) in the historical cohort. The survival of patients with extensive burns involving the perineal region was improved using FMS. No significant complications were reported in relation to the use of FMS. FMS allows faecal diversion, reduced perineal soiling and improved personal hygiene. We believe this allows easier management of these difficult injuries, may reduce the incidence of sepsis and improves survival.

Le but de cette étude est d'évaluer l'efficacité des systèmes de gestion de matières fécales dans l'amélioration de la survie des patients atteints de brûlures étendues impliquant le périnée. Tous les adultes souffrant de brûlures de plus de 30% de la superficie totale du corps (SCT) qui ont été traités activement dans notre centre régionale entre Décembre 2008 et Juillet 2012 étaient examinés et comparés à une cohorte historique de 18 patients adultes atteints d'une blessure similaire impliquant le périnée, traités dans notre centre entre 1999 et 2001. Pour les cinq dernières années, les systèmes de gestion de matières fécales (FMS) ont été utilisés pour les patients souffrant de brûlures étendues impliquant le périnée. Seize patients souffrant de brûlures supérieures à 30 % de la SCT impliquant la région périnéale ont été admis au cours de cette période et tous ont été gérés avec FMS. Quatre des 16 patients (25%) gérés avec FMS sont morts comparativement à 11 des 18 patients (61%) de la cohorte historique. La survie des patients atteints de brûlures étendues impliquant la région périnéale a été améliorée en utilisant FMS. Aucune complication significative n'a été signalée en ce qui concerne l'utilisation du FMS. FMS permet diversion fécale, réduit les salissures du périnée et améliore l'hygiène personnelle. Nous pensons que cela permet de faciliter la gestion de ces blessures difficiles, peut réduire l'incidence du sepsis et améliorer la survie.

Cause of death and correlation with autopsy findings in burns patients.

OBJECTIVE: Global mortality from burns is decreasing however there is a relative paucity of mortality data in the literature from burns units in the United Kingdom. We present an analysis of burns deaths and correlation with coroners' autopsy findings from a large regional burns unit. DESIGN: Retrospective medical note review of patients who died over a 7 year period (January 2005 to April 2011) was undertaken. Patient demographics were recorded in addition to: burn size, depth, length of stay, presence of inhalational injury, organs failing and diagnosis of sepsis. In order to evaluate the accuracy of our pre-mortem clinical diagnosis, we compared post-mortem cause of death with clinical cause of death. RESULTS: There were 92 deaths out of 4745 admissions for acute burn (crude mortality 1.9%). 37 patients were immediately given comfort care and excluded from analysis. Average age was 52.9 years±19.4, average percentage burn 43.7%±26.8, and length of stay 26.4±45 days. 80% of deaths were attributable to flame burn (44/55), and 51% (28/55) suffered inhalational injury. Multi-organ failure was the primary cause of death (39/55), with sepsis being the primary trigger (20/39, 51%). Pseudomonas was the most common organism isolated in septic patients. There were significant difficulties in obtaining post-mortem reports and an obvious lack of correlation between coroners' reports and clinical cause of death. CONCLUSIONS: The principal cause of mortality in our unit was multi-organ failure due to sepsis, which concurs with current literature. Autopsy has previously been shown to be a useful retrospective diagnostic tool, however we challenge its reliability as a result of our study.

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 Biobrane® to dress split-thickness skin graft in paediatric burns.

Biobrane(®) is commonly used in paediatric burns to cover partial thickness burns and donor sites of split thickness skin (SSG). The purpose of this study is to evaluate the use of Biobrane(®) in dressing SSG adjacent to skin graft donor sites or partial thickness burns. A retrospective review was undertaken to determine the use of Biobrane(®) in dressing SSG, where the grafted areas were adjacent to donor sites or partial thickness burns. Between 2009 and 2012, we reported five cases of using Biobrane(®) to dress SSG, where the grafted areas were adjacent to partial thickness burns and two cases where the grafted areas were adjacent to donor sites. Biobrane(®) promoted adherence of the SSG to the wound, prevented shearing, and allowed fluid drainage. At the same time, Biobrane(®) also facilitated healing of the adjacent donor sites or partial thickness burns.

Biobrane® est couramment utilisé dans les brûlures pédiatriques pour couvrir les brûlures d'épaisseur partielle et les sites donneurs de greffe de peau mince. Le but de cette étude est d'évaluer l'utilisation de Biobrane® sur les greffes de peau mince adjacentes aux sites donneurs des greffes de peau ou des brûlures d'épaisseur partielle. Une étude rétrospective a été menée pour éxaminer l'utilité de Biobrane® sur les greffes de peau mince où les zones greffées étaient adjacentes aux sites donneurs ou aux brûlures d'épaisseur partielle. Entre 2009 et 2012, nous avons enregistré cinq cas de l'utilisation de Biobrane® pour ce type de greffe, où les zones greffées étaient adjacentes à des brûlures d'épaisseur partielle, et deux cas où les zones greffées étaient à côté de sites donneurs. Biobrane® a promu l'adérence de la greffe à la plaie, a empêché de cisaillement, et a permis le drainage du fluide. Dans le même temps, Biobrane® a également facilité la guérison des sites donneurs adjacentes ou les brûlures d'épaisseur partielle.

Staphylococcal scalded skin syndrome due to burn wound infection.

UNLABELLED: Introduction. The staphylococcal scalded skin syndrome is an acute exfoliation of the skin caused by exfoliative toxins A and B. Although Staphylococcus aureus is a common cause of burn wound infection, SSSS following burn wound infection is rare. Method. A retrospective review of all SSSS cases admitted to a regional burns service between January 2008 and January 2012 was undertaken. Results. Two cases of SSSS were reported during this time period as occurring following burns injury. The first case was a 17-month-old boy who had been hospitalized for a conservative treatment of 6% total body surface area (TBSA) mixed depth scald burns. On day four he developed exfoliation of 85% TBSA. The second case was a ten-month-old boy who sustained a 1% TBSA scald burn and was managed conservatively in the community by his general practitioner. On day five, he developed exfoliation of 80% TBSA. Staphylococcus aureus was isolated from the burn wounds in both cases. CONCLUSION: These two cases show that it is vital for burns surgeons and intensive care specialists to be aware of the possibility of SSSS occurring in patients with burn injuries with its potential devastating effects.

Introduction. Le syndrome de la peau ébouillantée staphylococcique (sigle anglais conventionnel, SSSS) est une exfoliation aiguë de la peau causée par des toxines A et B. Bien que le Staphylococcus aureus soit une cause fréquente d'infection des brûlures, la SSSS suite à une infection brûlure est rare. Méthode. Les Auteurs ont effectué une revue rétrospective de tous les cas de patients atteints de SSSS hospitalises admis dans un service régional des brûlures entre janvier 2008 et janvier 2012. Résultats. Deux cas de SSSS ont été signalés au cours de cette période qui se sont produits suite à une brûlure. Le premier cas était un garçon de 17 mois qui avait été hospitalisé pour un traitement conservateur pour ébouillantement dans 6% de la surface corporelle totale de profondeur variable. Le quatrième jour, il a développé une exfoliation dans 85% de la surface corporelle. Quant au deuxième cas, il s'agissait d'un garçon de dix mois qui a subi une brûlure de 1% de la surface corporelle et qui a été traité en manière conservatrice dans la communauté par son médecin généraliste. Le cinquième jour, il a développé une exfoliation dans 80% de la surface corporelle. Le Staphylococcus aureus a été isolé qui provenait des brûlures dans les deux cas. Conclusion. Ces deux cas montrent qu'il est essentiel que les brûlologues et les spécialistes des soins intensifs soient au courant de la possibilité de la présence de SSSS chez des patients souffrant de brûlures, avec tous ses potentiels effets dévastateurs.