WALANT: Perceptions, approaches, and contraindications in a tertiary hand surgery unit.

Wide awake local anesthetic no tourniquet (WALANT) is gaining popularity amongst hand surgeons. Digital adrenaline use has been shown to be safe in multiple studies and the misconception forbidding it is receding. Phentolamine has been shown to safely reverse the effects of adrenaline should the feared complication of digital ischemia occur. A survey was circulated to 40 specialist practitioners who regularly perform hand procedures at a major tertiary plastic and hand surgery unit. Knowledge and understanding of WALANT, onset and duration of adrenaline effects and reversal was assessed. Whilst the majority of respondents (80%) recognized digital adrenaline use as safe, only 65% were aware of the delay until adrenaline takes full effect. Similarly, only 25% of respondents were aware of the duration of effect of adrenaline. Half of respondents were aware that phentolamine is the established reversal agent for adrenaline with only 20% knowing the correct dose. Given the lack of clinician knowledge surrounding adrenaline and its reversal, we feel that to safely undertake WALANT surgery at our Unit a WALANT protocol must be implemented. Drawing on the successes in the airline industry, a variety of safety frameworks have been established to deliver targeted education for prevention and eventual management of predictable risks. We plan to develop a checklist style protocol targeting the knowledge gaps raised in the survey. This will educate and equip all practitioners working with adrenaline with the knowledge to safely manage complications should they occur. LEVEL OF EVIDENCE: Level 5 (UK Oxford Centre for Evidence based Medicine (CEBM) Levels of Evidence).

Self-inflicted Burns: 10 year review and comparison to national guidelines.

INTRODUCTION: There is an increasing trend of self-inflicted burns noted in the literature, often seen in patients with complex psychosocial backgrounds. These patients are challenging to manage as the recovery from the acute burn may be compounded by difficult rehabilitation and suboptimal coping strategies. We aimed to review patients presenting to our burns unit with self-inflicted burns, the management strategies and examine the complexities surrounding their management. We assessed patient outcomes with a particular interest in psychosocial support given. METHODS: A retrospective review of all patients presenting with self-inflicted burns over a 10 year period (2005-2014 inclusive) was conducted. Patients were identified through IBID database coded as either 'self-inflicted' or 'suicidal.' We reviewed patient and burn demographics, the clinical management, psychosocial management and patient outcomes such as wound healing, re-admission rates, and survival. RESULTS: We identified 118 self-inflicted burns in total. 50/118 (42%) were admitted. 64 (54%) were male and the total body surface burn area ranged from <0.5% to 99% with a median of 14%. 60/118 (51%) had TBSA <10% and 58/118 (49%) had TBSA >10%. 24 (48%) underwent admission to the Burn Intensive Care Unit (BITU). All patients admitted to BITU had TBSA >10%. Of those admitted to BITU 6 were palliative, 18 had full resuscitation and surgical management. Of those 18 patients who had active treatment, 10/18 (56%) died. Mean total length of stay was 31 days, range 1-130 days. 9% of patients sustained injuries whilst being a current inpatient at a psychiatric institution. Of all patients reviewed, 16% (n=19) had a previous history of deliberate self-harm through burns. Of those patients admitted, 98% of were reviewed by the mental health team during their admission with time to psychological review varying depending on fitness for assessment. The overall mean length of stay for all admitted patients who were actively treated but who subsequently died was 53 days. 84% of admitted patients were managed surgically. CONCLUSION: Self-inflicted burns patients would benefit from a more complex pathway of treatment as their management aims to achieve not only physical health but also psychological health. They would benefit from enhanced care to manage the acute burn but also psychiatric support to ensure patients do not re-offend.

Is Achenbach's syndrome a surgical emergency? A systematic review.

AIM: The aim of this study is to establish the nature (urgent vs. non-urgent), demographics, presentation and management of Achenbach's syndrome and to formulate an algorithmic approach for their diagnosis and management. MATERIALS AND METHODS: A systematic review and met-aggregation of literature from 1944 to 2015 in English language in MedLine, Embase and Cochrane database were conducted. RESULTS: Achenbach's syndrome is a female-dominant disease with median age of 49.5 years (range 22-76) (age ≤60, n = 11/12, 91 %). It presents with unilateral volar discoloration of a finger (100 %). It is associated with pain (n = 7/12, 58. %), edema (n = 7/12, 58 %), and paresthesia (n = 3/12, 25 %). The median time to resolution of symptoms without any intervention was 4 days (range 2-14). CONCLUSION: AS is self-limiting and a non-urgent surgical condition. It can be differentiated from other pathologies by clinical spectrum, patient demographics and in doubtful circumstances (acute limb ischemia) by Doppler sonography. An algorithmic approach can avoid hospital admissions, partially unnecessary investigation and assist in patient assurance.