Bromelain-based enzymatic debridement of e-cigarette burns: a single unit experience.

OBJECTIVE: It is widely accepted that the early debridement of burns improves outcome. There is increasing evidence that enzymatic debridement is an effective technique for removal of full-thickness and deep-dermal burns, reducing blood loss and often the need for autologous skin grafting by avoiding over excision of the burn. We aim to highlight the potential use of this form of debridement as an alternative to surgical management in patients with electronic cigarette (e-cigarette)-associated flame burn injuries. METHODS: This case series presents the use of Nexobrid (MediWound Ltd, Israel), a non-surgical, bromelain-based enzymatic debridement technique, in patients with deep partial-thickness burns (range: 1-3% total body surface area), avoiding the need for autologous skin grafting. RESULTS: Burn wounds in two patients healed within 14 days without complications or the need for further surgical intervention. Another patient required further dressings after discharge but failed to attend follow-up appointments. These results are comparable with those reported by others using conservative management of e-cigarette burns. CONCLUSION: The authors wish to raise awareness of the potential for a combination of thermal and chemical burns related to e-cigarette explosions. Chemical burns should be excluded by pH testing of the burn wound. From our experience, small e-cigarette-associated flame burns can be considered for management with enzymatic debridement.

E-cigarette burn injuries: Comprehensive review and management guidelines proposal.

INTRODUCTION: Electronic cigarettes (EC) have been reported to be associated with burns secondary to explosions of the device or battery, or contact from overheating, resulting in flame, contact or chemical burns. In addition to this, there have also been reported cases of soft tissue and bony trauma with or without associated burns. Using collective evidence, this review aims to summarise all reported burns associated with ECs, and its implications on immediate management with a particular focus on surgical treatment. METHODS: A search was conducted on PubMed, EMBASE and Medline for all case reports, case series and letters to editors published since 2014, using terms "electronic cigarette", "e-cigarette", "vaping" and "burn". The search was repeated by the co-author to avoid bias and a review of the bibliographies of each paper was conducted to ensure all relevant cases were included. The mechanisms, type and severity of burn injury, and management and treatment outcomes of the patients were recorded. Exclusion criteria included non-English articles, explosions with no associated burn and publications with insufficient information. RESULTS: 90 patients from 19 case series or case reports were included. With the exception of one study, gender was recorded with a male predominance (95.6%). Mean age is 30.1years (range 18-59). The most common type of burn was flame. However, there were reports of chemical burns associated with ECs. The mean total body surface area (TBSA) affected was 4.9% (range 1-27.25%) with the majority of burns being mixed partial and full thickness. 22 patients underwent excision and autologous skin grafting within range of three to 21days. One patient had a full thickness contact burn excised and closed, one patient received a xenograft following debridement and one had biosynthetic skin dressing. 42 patients were managed conservatively with dressings or ointments. DISCUSSION: In this review over a three-year period (2015-2017), 90 cases of EC related burn injuries were reported, however, this is likely an underestimation of the problem. The suggested mechanism for EC related injuries is battery malfunction. ECs are powered by Lithium ion batteries which are susceptible to "thermal runaway" reactions, which result in device overheating with potential for subsequent explosion. We explain hypothesized triggers for these reactions and mechanisms of other injuries associated with ECs such as chemical burns and blast injury. CONCLUSION: EC-associated burn injury results in combined thermal and chemical burns, which should be managed in tandem. Explosion injuries sustained whilst using the device may result in both facial trauma or inhalation injury and therefore should be reviewed with a high index of clinical suspicion. It is noted that there is no agreed standard for management for such burns by specialist bodies in the UK. We suggested a treatment algorithm to provide guidance for the burn injuries associated with ECs.

Surgical and psychiatric profile of patients who self-harm by burning in a regional burn unit over an 11-year period.

INTRODUCTION: Patients admitted to hospital for deliberate self-harm by burning (DSHB) provide a challenge for medical, surgical and psychological management. We retrospectively reviewed all the patients admitted to a Scottish regional burn unit with DSHB over an 11-year period to assess demographics and outcome. METHODS: Ward admission data were used to identify DSHB patients admitted to the South East Scotland regional burn unit in Livingston, UK between 2002 and 2012, as well as a control group of accidental burn patients. Data were extracted concerning burn injury, psychiatric history and inpatient management. RESULTS: A total of 53 DSHB patients with 58 attendances over the 11-year period were compared to 49 accidental burns patients. Compared to controls, DSHB patients were more likely to be unemployed, live alone and have a previous psychiatric diagnosis (p < 0.01). DSHB patients had more severe burns, a longer hospital stay and were more likely to undergo surgery (p < 0.01). DSHB patients with previous self-harm, suicide attempts and diagnoses of personality and eating disorder all had significantly less severe burns than DSHB patients without these risk factors (p < 0.05). CONCLUSIONS: In our experience, DSHB patients have more severe burn injuries and require longer, resource-intensive hospital stays. Burn units should have an appropriate specialist psychologist/psychiatrist who works within the Burn multi-disciplinary team to help manage this complex group of patients' healthcare needs and reduce their risk of further self-harm.

Intrapleural bupivicaine in latissimus dorsi breast reconstruction.

The use of intrapleural (IP) analgesia for controlling post-operative pain in breast reconstruction is not well documented. The objective of this study was to assess the value of IP bupivacaine in those patients undergoing latissimus dorsi breast reconstruction. Twenty-six patients received a single bupivacaine IP injection at induction of anesthesia. Eighteen of these patients also received a 24-hour postoperative IP infusion. A control group of 22 patients did not receive an IP block. All patients had access to morphine via patient-controlled analgesia pumps. The 24-hour morphine requirements were recorded for each group and the data were analyzed by Student t test. Significance was taken at the 5% level. The mean morphine requirement in the control group was 39.2 mg +/- 2.89 mg. This was significantly greater than the requirement of the 8 patients who had a single IP injection of bupivacaine at induction (10.1 mg +/- 2.76 mg), P < 0.001. It was also significantly greater than that of the 18 patients who received an IP infusion (2.7 mg +/- 1.35 mg), P < 0.0001. The infusion group required significantly less morphine than the single injection group did, P < 0.02. No complications following IP injection were noted in this series. Intrapleural analgesia is a safe technique and significantly reduces the requirement for postoperative opiate analgesia in those undergoing latissimus dorsi breast reconstruction.