Safety of troclosene sodium solution in decontamination of wounds: A prospective clinical and laboratory study.

Debate persists regarding the safety of hypochlorite-containing solutions in the decontamination of infected wounds. In 2006, the Israeli Ministry of Health withdrew licensing approval for troclosene sodium as a wound irrigation solution. The aim of this prospective clinical and laboratory study was to investigate the safety of troclosene sodium solution for decontamination of infected wounds. Troclosene sodium solution was used to treat 30 patients with 35 infected skin wounds of various etiologies and body areas, over a treatment period of 8 days. Data were gathered according to a prospectively designed protocol including general findings, wound-specific observations on Day 1 and Day 8 and laboratory parameters on Day 1 and Day 8. Wound swabs and tissue biopsy for culture were taken on Day 1 and Day 8. Statistical analysis was executed. Tests were 2-sided and p values of <0.05 were considered statistically significant. Eighteen males and 12 females, with 35 infected skin wounds were enrolled. There were no adverse clinical events. No significant changes were observed in general clinical observations. Statistically significant improvements were observed in: pain (p < 0.0001); edema (p < 0.0001); area of wound covered by granulation tissue (p < 0.0001); exudate (p < 0.0001); and erythema (p = 0.002). Prior to treatment, bacteria were demonstrated on microscopy or on culture in 90% of wound samples. On Day 8, this frequency reduced to 40%. There were no abnormal laboratory tests. Serum sodium concentration increased significantly between Day 1 and Day 8, whilst serum concentration of urea and concentrations of thrombocytes, leucocytes and neutrophils showed statistically significant reductions, but all values remained within normal laboratory ranges throughout the study period. Troclosene sodium solution is clinically safe in the management of infected wounds. These findings were presented to the Israel Ministry of Health and as a result, troclosene sodium was re-approved and licensed for decontamination of infected wounds in Israel.

To bleed or not to bleed? Case series and discussion of haemorrhage risk with enzymatic debridement in burn injuries.

Introduction: Surgical burn excision (along with skin grafting) carries the risk of blood loss. The use of enzymatic debridement agents such as Nexobrid® has gained increased popularity as an alternative to surgical debridement in the management of burns with its reported benefits of selective burn debridement, minimising blood loss and potentially reducing the need for skin grafting. However, there is limited evidence regarding its effects on bleeding. Currently, the manufacturer declares there is no evidence for increased risk of localised bleeding and its systemic effects upon coagulation are less clear. Methods: We present two clinical cases demonstrating the possible effects of Nexobrid® on coagulation and bleeding at the debridement site. Comparisons are drawn with the manufacturers' guidance as well as evaluating the current recommendations of its use. Discussion: Nexobrid® is a novel therapy and there are few adverse effects reported in the literature. The basis of its appeal is the reduced blood loss at the debridement site and the selectivity it possesses in preserving healthy dermis. However, our cases have demonstrated that haemorrhage can occur and that those using Nexobrid® should be mindful of the potential bleeding risk from varicosities within the burn wound. We have also illustrated that Nexobrid® can be used in patients with pre-existing clotting disorders without requiring the use of blood products. However, we emphasise the importance of haematological support for its safe administration. Lay Summary: Nexobrid®, a debriding agent that contains enzymes, has been developed as an alternative to surgery which for most surgeons is the traditional method of removing dead tissue following a burn injury. The active agent is bromelain and this is derived from the stems of pineapples. This novel treatment is increasingly being used in the management of middle to deep skin thickness burns and it seems to have a number of benefits such as reducing blood loss, reducing the need for skin grafting as well as being able to treat burns in certain areas of the body that would be technically challenging to remove in the standard fashion. It simply targets the dead tissue leaving viable remnants of the skin that would hopefully allow healing to occur without the need for surgical intervention. Being a relatively new concept, current evidence regarding the safety and value of Nexobrid® continues to develop. In 2020, an agreement guideline outlining best practice with the use of Nexobrid® was published. In this statement, it was advised that caution should be taken when using Nexobrid® in patients who have blood clotting disturbances as this could increase the likelihood of bleeding. However, they did not mention that excessive bleeding can potentially occur with this treatment.We present two clinical cases demonstrating the possible effects of Nexobrid® on the clotting system and bleeding at the application site. Comparisons are drawn with the manufacturers' guidance as well as assessing the current recommendations of its use. We illustrate that Nexobrid® can be safely used in patients with pre-existing clotting disturbances if the correct procedures are performed. We also highlight the potential complication of excessive bleeding if Nexobrid® is used in patients who have co-existing enlarged surface veins along with their burn injury. We feel the guidance should be updated to reflect these findings.

Positive outcomes for operatively managed self-harm burns.

Within healthcare generally, patients who self-harm can experience stigma and inequitable medical care. Previous studies have suggested that patients with small self-harm burn injuries may not be treated equally in comparison to non-intentional injuries. Furthermore, there is an absence of literature related to surgical outcomes for self-harm burn injuries. A retrospective cohort study of an adult burns service's outpatient attendances over a four-year period was completed. Self-harm burn injuries were identified and hospital medical records were used to extract demographic, burn injury, treatment and outcome information. 94 self-harm burn injuries in 58 patients presented over the study period. Of those who presented with self-harm burn injuries, 29 % (n = 17) of patients presented on more than one occasion, 54 % (n = 50) of wounds were managed surgically and 80 % (n = 36) of full thickness injuries were managed surgically. The post-operative course and healing time was similar to what would be expected after non-intentional burn injuries. In 93 % (n = 54) of all patients presenting with self-harm burn injuries, there was no reported tampering or non-compliance. There was no tampering or non-compliance in 94 % (n = 47) of those with self-harm burn injuries when wounds were treated surgically. The findings support the view that self-harm burn injuries should be treated in the same way as non-intentional burn injuries and that similar outcomes from treatment can be expected. However, further research is needed to explore this systematically.

Human cadaver model as a training tool for enzymatic burn debridement (Nexobrid®): A feasibility study.

OBJECTIVES: To determine the feasibility of using human cadavers to demonstrate enzymatic burn debridement, as a training aid for clinical staff. MATERIAL AND METHODS: A single, fresh-frozen human cadaver was used. Prior consent had been given. Burns were created by flame and scalding. Unburned control sites were also assessed. Nexobrid® enzymatic burn debridement paste was applied to all sites, in adherence to the local clinical protocol for treating burned patients. After removal of Nexobrid®, wounds were assessed to determine if the cadaveric tissue appeared similar to what would be expected in living burned patients and whether the technique could be viable for training of burn care staff. RESULTS: Nexobrid® had a very similar effect upon burned cadaveric skin to what would have been expected in living burned skin. Burns of partial thickness burn depth and full thickness burn depth were debrided and could be clearly identified. CONCLUSIONS: Fresh-frozen human cadaveric tissue is a valid means of provision of training in the technique of enzymatic burn debridement. This finding was unexpected and shows that our understanding of the mechanism of action of Nexobrid® is incomplete.

Evaluation of EpiProtect® microbial cellulose burns dressings in young children.

INTRODUCTION: EpiProtect® is a biosynthetic cellulose dressing indicated for the treatment of superficial burns and the dressing of deep burns. Prior to this study the youngest reported patient treated with EpiProtect® was aged 13 years. METHOD: Data were collected prospectively for patients aged < 5 years, presenting to the Children's Burns Unit with ⩾ 2% total body surface area (TBSA) burns sustained by any mechanism. RESULTS: Thirty children were treated (median age = 17 months, age range = 1-61 months). Thirty-six burn depths were documented: superficial partial thickness (SPT) in 53% (n=19); mid-partial thickness (MPT) in 33% (n=12); deep partial thickness (DPT) in 11% (n=4); and full thickness (FT) in 3% (n=1). Median burn size was 4.5% TBSA (range = 2%-12%). EpiProtect® was applied under general anaesthesia in all cases. The median length of stay (LOS) was two days (range = 0-6 days). EpiProtect® was tolerated well and provided effective analgesia for subsequent dressing changes. Median healing time was 13 days (SPT burns), 14 days (MPT) and 24 days (DPT burns). Three patients required split skin grafting. Hypertrophic scarring arose in one patient. DISCUSSION: This case series represents the youngest published patient group to have been treated with EpiProtect®. Authors conclude that EpiProtect® provides a safe, reliable and well-tolerated dressing option for all burn depths in young children. Importantly, EpiProtect® is culturally neutral and may be used in situations which, for cultural reasons, may preclude the use of animal-derived products. Further studies are warranted to evaluate pain scores, burn depth, size and LOS correlation, and comparative analysis between dressing types. LAY SUMMARY: Burn injuries in the paediatric population are common and often require multiple dressing changes. Dressing changes can be painful and distressing to both children and their care givers. This article describes the experience of using a synthetically derived burns dressing, called EpiProtect®, in children aged ⩽ 5 years. Thirty patients were recruited with varying depths of scald burns and all underwent application of EpiProtect® dressing. The results suggested that EpiProtect® was a user-friendly dressing that can be used to treat partial-thickness burns and to dress full-thickness (FT) burns. It was well-tolerated and provided effective analgesia at the time of dressing changes. There was no incidence of increased burn wound infection rates and all wounds healed. In addition, as EpiProtect® is a synthetic product, it has the benefit of being culturally neutral, which is advantageous in a culturally diverse population. Further studies are warranted to evaluate the effectiveness of this dressing and to compare it to similar dressings that are available.

Quantitative and thematic analysis of burns surgeons' attitudes, beliefs and surgical decision-making in self-harm burn injuries: The use of a questionnaire and hypothetical cases.

BACKGROUND: Self-harm injuries represent a significant minority of attendances within burns services. However, there is minimal research exploring burns surgeons' attitudes and beliefs about self-harm and how treatment decisions are made. METHOD: Burns surgeons (n=37) completed a questionnaire which measured attitudes and beliefs about self-harm. Surgical decision-making was also explored by prompting surgeons to make treatment decisions for hypothetical case scenarios, and describe their rationale behind their decisions. RESULTS: The majority of surgeons reported positive attitudes about self-harm. However, around one in ten judged patients who self-harm more negatively, around a fifth offer surgery less frequently and almost a quarter believed that surgery should only be offered a limited number of times in repeated self-harm. Unhelpful or inaccurate beliefs (e.g. self-harm is 'attention seeking,' surgery would reinforce the self-harm, and that patients who self-harm tamper with skin grafts) were evident in some surgeons. Thematic analysis of qualitative data describing surgical decisions identified five themes: Equal Access to Care; Multidisciplinary Working; Old or Unhelpful Stories; Concerns about Tampering; and Repeated vs. First Time Self-Harm Episodes. More experienced surgeons were less judgmental, more likely to offer surgical interventions, and less likely to hold unhelpful or inaccurate beliefs compared to junior surgeons. CONCLUSIONS: Some surgeons are not acting in line with UK guidance on the management of self-harm injuries. Education on the topic of self-harm is essential in burns services and this may be particularly important early on during surgical careers. Prospective research regarding surgical treatments and outcomes following self-harm is required.

The role of psychological flexibility in appearance anxiety in people who have experienced a visible burn injury.

BACKGROUND: Individuals with visible differences can experience appearance anxiety that is distressing and disruptive to daily functioning. Understanding psychological factors that maintain appearance anxiety related to scarring is important in developing theoretical understanding of adjustment to injury, and in identifying targets for psychological therapies. This study aimed to investigate whether psychological flexibility, a key element underpinning acceptance and commitment therapy (ACT), was associated with appearance anxiety. It was hypothesised that reduced psychological flexibility (lower acceptance, cognitive defusion, mindfulness, and committed action) would be related to increased appearance anxiety. The role of psychological flexibility in the maintenance of appearance anxiety was investigated using a cross-sectional quantitative questionnaire study. METHOD: Seventy-eight burns patients (47 female, 31 male; M age=45.2years) completed the Derriford Appearance Scale (DAS-24), the Acceptance and Action Questionnaire (AAQ-II), the Cognitive Fusion Questionnaire (CFQ), the Five Facet Mindfulness Questionnaire (FFMQ), and the Committed Action Questionnaire (CAQ-8). RESULTS: As hypothesised, increased appearance anxiety was related to reduced acceptance (rs(76)=0.80, p<0.001, one-tailed) and cognitive defusion (rs(76)=0.76, p<0.001). Reduced levels of mindfully describing (r(72)=-0.39, p<0.001), acting with awareness (r(72)=-0.57, p<0.001), non-judging (r(72)=-0.61, p<0.001) and non-reactivity (r(72)=-0.28, p<0.01) as well as reduced committed action (r(72)=-0.57, p<0.001) were also related to increased appearance anxiety. CONCLUSIONS: Individuals experiencing appearance anxiety associated with a burn injury may struggle with accepting difficult emotions, stepping back from distressing thoughts, being mindful and engaging in valued action. These findings suggest that ACT may be useful in treating appearance related anxiety and concerns associated with conditions causing a visible difference.

Audit of healthcare professionals' attitudes towards patients who self-harm and adherence to national guidance in a UK burns and plastic surgery department.

BACKGROUND: Rates of self-harm injuries are considered to be increasing. The attitudes of healthcare staff towards patients who self-harm may be negative and a small amount of research specifically investigating burns and plastic surgery healthcare professionals has recently been conducted exploring this issue. This study aimed to determine attitudes towards and adherence to national guidance by healthcare professionals in a UK burns and plastic surgery department with respect to patients who self-harm. METHOD: An audit questionnaire, completed in a designated Burns Unit and plastic surgery department, within a UK hospital with a major trauma centre. RESULTS: Data were obtained from 59 healthcare professionals. The majority of responders held positive attitudes towards those who had self-harmed. However, a significant minority held negative attitudes, stating that they found it difficult to be compassionate (10%; n = 6) and believing that patients usually self-harm to get attention (9%; n = 5). One-fifth (n = 12) agreed that, on a departmental level, conservative management (as opposed to surgery) was offered more frequently for self-harm injuries compared with accidental injuries, contrary to national guidance. Awareness of national guidance in relation to self-harm injuries was markedly lacking, in only 12% (n = 7/59) and the frequency of completing relevant training was low (34%, n = 20/59). CONCLUSION: Education among healthcare professionals is important, to ensure adherence to best practice. The findings of this study strongly suggest that many healthcare professionals do not know the current best practice. As a result, these highly vulnerable patients may be receiving sub-optimal care, with consequentially poor outcomes.

Response of a local hospital to a burn disaster: Contributory factors leading to zero mortality outcomes.

OBJECTIVE: To investigate the outcomes of a local healthcare system in managing a burn mass casualty incident (BMCI). METHODS: Thirty-three victims admitted to the National Taiwan University Hospital within 96h of the explosion were included in the study. Data were recorded on: patient demographics, Baux score, laboratory data, management response, treatment strategies, and outcomes. Case notes from June 27, 2015 to November 2015 were reviewed with a focus on fluid resuscitation, ventilation support, nutrition, infection control, sepsis treatment, and wound closure plan. RESULTS: Female predominance (mean age: 21.7 years) and lower extremity circumferential flame burns were the characteristics of the burn injury. The mean Baux score was 70±18. The mean burn area was 42% of the total body surface area (TBSA). A total of 79% patients arrived at the hospital within 24h of sustaining injuries. Intensive care unit (ICU) admission criteria were modified to accommodate patients with 40% TBSA of burns, facilities were expanded from 4 ICU beds to 18 beds, and new staff was recruited. A total of 36% patients (n=12/33, 62±13 TBSA of burns) required fluid resuscitation. The mean volume of Lactate Ringer administered in the first 24h of burns was 3.34±2.18ml/kg/%TBSA, while the mean volume of fresh frozen plasma administered was 0.60±0.63ml/kg/h. Forty-two percent patients were intubated on the day of admission, and 71% of the intubated patients had inhalation injuries that were confirmed by diagnostic bronchoscopy. The mean intubation period was 17±9 days. The incidence of pulmonary edema was 58% (n=7/12), possibly due to sub-optimal monitoring. Of these, 57% (n=4/7) patients progressed to adult respiratory distress syndrome, but were successfully treated with early strict fluid restriction, systemic antibiotics, ventilation support, and bronchial lavage. A total of 94% patients received grafting. The mean grafted area was 4432.3±3891cm2. Tube feeding was provided to patients with burns >40% TBSA. All patients tolerated gastric tube feeding without conversion to duodenal switch. On admission, all patients received prophylactic antibiotics. Septic shock was noted in 12 patients, but no mortality occurred. The mean hospital stay was 1.5 days per percent burn. CONCLUSIONS: This article highlights the value of precise triage, traffic control, and effective resource allocation in treating a BMCI. Effective supporting systems for facility expansion, staff recruitment, medical supplies and clear-cut treatment strategies for severely burned patients are contributory factors leading to zero mortalities in our series, in addition to young age and minimal inhalation injuries. The need for reevaluation of the safety of cornstarch powder in festival activities is clear.

Brain tumour presenting with burns: Case report and discussion.

Descriptions of burns as the presenting features of underlying neurological pathology are very rare, with only two previously published case reports available. Both of these reports featured meningioma as the pre-existing pathology and both described burn excision and wound healing, prior to surgical tumour ablation. The authors describe the case of a 35-year-old female, who presented with 25% total body surface area burns and recent global neurological deterioration. MRI imaging revealed a large intracranial tumour. Multidisciplinary management included rigorous non-surgical burn wound care and early craniotomy and tumour excision. This proceeded without complication. Burn excision and skin grafting was carried out successfully, two weeks later. This case differs from the previous two reported cases, which both described burn excision, as a pre-requisite to neurosurgery. This case establishes that the presence of a burn wound is not a total contra-indication to intracranial surgery.

Intralesional cryotherapy for hypertrophic scars and keloids: a review.

INTRODUCTION: Hypertrophic and keloid scarring remain notoriously troublesome for patients to tolerate and frustratingly difficult for clinicians to treat. Many different treatment modalities exist, signifying the failure of any method to achieve consistently excellent results. Intralesional cryotherapy is a relatively recent development that uses a double lumen needle, placed through the core of a keloid or hypertrophic scar, to deliver nitrogen vapour, which freezes the scar from its core, outwards. METHODS: This article provides a comprehensive review of the literature on intralesional cryotherapy for hypertrophic scars and keloids. A systematic review or meta-analysis was not possible, since the existing articles did not permit this. RESULTS: A search of English language, peer-reviewed literature was carried out. The evidence base was found to be low (level 4). In addition, much of the published evidence comes from a very few groups. Despite this, consistent findings from case series suggest that the technique is safe and achieves good scar reduction with very few treatments. Adverse effects include depigmentation, recurrence and pain. Pain and recurrence appear to be uncommon and depigmentation may be temporary. DISCUSSION: Well-constructed, prospectively recruited comparative trials are absent from the literature. These are strongly encouraged, in order to strengthen general confidence in this technique and in the repeatability of outcomes reported thus far.

Facial burns from exploding microwaved foods: Case series and review.

INTRODUCTION: Microwave ovens allow for quick and simple cooking. However, the importance of adequate food preparation, prior to microwave cooking, and the consequences of inadequate preparation are not well-known. METHOD: The authors conducted a retrospective outcome analysis of all patients who sustained facial burns from microwaved foods and were treated at a UK regional burns unit over a six-year period. Patients were identified from clinical records. RESULTS: Eight patients presented following inadequate preparation of either tinned potatoes (n=4) or eggs (n=4). All patients sustained <2% total body surface area facial burns. Mean age was 41 years (range 21-68 years). Six cases (75%) had associated ocular injury. One received amniotic membrane grafts; this individual's vision remains poor twelve months after injury. DISCUSSION: Rapid dielectric heating of water within foods may produce high steam and vapour pressure gradients and cause explosive decompression [1,5,11]. Consumers may fail to recognise differential heating and simply cook foods for longer if they remain cool on the outer surface. Education on safe use and risks of microwave-cooked foods may help prevent these potentially serious injuries. CONCLUSION: Microwave ovens have become ubiquitous. The authors recognise the need for improved public awareness of safe microwave cooking. Burns resulting from microwave-cooked foods may have life-changing consequences.

Man or machine? The clinimetric properties of laser Doppler imaging in burn depth assessment.

Burns of an indeterminate depth present a challenge to burns surgeons and nurses on a daily basis in terms of healing and subsequent management, be it by a surgical or a more conservative approach. Laser Doppler imaging has become an important diagnostic modality in assisting the clinical decision-making process, being used widely in burns units throughout the United Kingdom and the rest of the world. Clinimetrics focuses on the methodology of measuring various biological parameters, and this article aims to describe laser Doppler imaging in this context by appraising the current body of evidence that illustrate its various properties. The authors conclude that indeterminate burn depth assessment should be a clinical judgment assisted by information provided by this device.

Evaluation of single-, double-, and triple-nerve transfers for shoulder abduction in 90 patients with supraclavicular brachial plexus injury.

BACKGROUND: Shoulder stability and mobility are critical to upper extremity function. The authors evaluated and compared the results of single-, double-, and triple-nerve transfer techniques in producing shoulder abduction in supraclavicular brachial plexus injuries. METHODS: Between January of 2000 and December of 2004, 90 patients with avulsion type brachial plexus injuries were selected for this study. All patients were operated on by the senior surgeon (D.C.C.C.). The brachial plexus injuries involved avulsion of five or six (including C4) roots in 41 patients (45.6 percent), four-root avulsion in five patients (5.6 percent), three-root avulsion in 25 patients (27.8 percent), two-root avulsion in 15 patients (16.7 percent), and one-root avulsion in four patients (4.4 percent). Ages ranged from 2 to 67 years, with a mean age of 29 years. All patients had nerve transfer for shoulder abduction: 43 (47.8 percent) received a single-nerve transfer, 43 (47.8 percent) received a double-nerve transfer, and four patients (4.4 percent) had a triple-nerve transfer for shoulder function. All patients had a minimum of 3 years' follow-up. Each patient's ability to abduct the shoulder was measured in degrees, and the measurements were compared statistically by nonparametric means. RESULTS: The average degree of shoulder abduction attained was 160 degrees following triple-nerve transfers, 85 degrees following double-nerve transfers, and 65 degrees following single-nerve transfer. The shoulder abduction achieved following either double-nerve transfer or triple-nerve transfer was significantly greater than that achieved by single-nerve transfer. CONCLUSION: Increasing the number of donor nerves used in early-stage nerve transfers to neurotize the avulsed brachial plexus appears to improve subsequent shoulder abduction.

Metformin-associated lactic acidosis in a pregnant patient.

Metformin-associated lactic acidosis is a rare but serious condition and potentially even more hazardous during pregnancy. We reported a case of lactic acidosis in a 28-year-old pregnant woman (gravida 3, para 0, abortion 2, ante-partum 22 weeks) after ingestion of 39.50 g (approximately 80 tablets) metformin in a suicide attempt. She had no pre-existing systemic illness. Analysis of arterial blood gases revealed a high anion gap (28.1 mEq/l) and a normal osmol gap (8 mEq/l) metabolic acidosis. Other etiologies of high anion gap and normal osmol gap metabolic acidosis were excluded by laboratory investigation. The patient was treated on an emergency basis and received aggressive fluid management, intravenous sodium bicarbonate (1 mEq/kg) and activated charcoal, orally. The fetal condition was monitored intensively. The fetus was delivered smoothly via vaginal delivery in a healthy state at the 38th gestational week. Clinical follow-up over the next 2 years confirmed no congenital abnormality. We present a case of successful management of metformin-associated lactic acidosis during pregnancy, treated simply, with intravenous sodium bicarbonate and intensive fetal monitoring. This relatively noninvasive method is an effective treatment option. However, hemodialysis still has a valuable role in the management of acidosis which proves refractory to conservative treatment, such as that described.

Occult brain tumour presenting with burns.

An elderly male patient sustained mixed depth burns of 5% total body surface area. The incident was associated with inappropriate behaviour and subsequent clinical examination confirmed the presence of confusion and a hemiparesis. A CT scan revealed an intracranial tumour. Despite early suspicions that tumour excision would be delayed, wound healing was achieved quickly following tangential burn wound excision and skin grafting, and prompt transfer to a neurosurgical unit was expedited. Cases of burns and concomitant intracranial tumours with deteriorating neurological signs may present clinicians with a dilemma in deciding whether or not to await burn wound healing before carrying out tumour excision.