Carbon dioxide laser for precise and bloodless contouring of soft tissue ahead of skin grafting-A case example of technique and benefits.

Scarring is a dynamic development as a result of the wound healing process. Post-burn scars are often hypertrophic in nature and thus exhibit a much thicker and firmer scar, often leading to contractures. Various strategies have been implemented by burns surgeons to endeavour to mitigate and improve such symptoms and appearances. Laser therapy in the control of hypertrophic scarring is of continual developing interest within this field. We demonstrate the advantageous, intra-operative use of a carbon dioxide laser for precise contouring of a burn scar prior to skin grafting in a 36 year-old female with hypertrophic scarring following a 65% total body surface area flash flame burn. This method provided a bloodless surgical field with no post-operative complications, good graft take and a favourable cosmetic outcome.

Review of Burn Resuscitation: Is Plasmalyte® a Comparable Alternative to Ringer's Lactate?

Ringer's lactate has been the most widely used fluid for burn resuscitation for decades. Plasmalyte® (PL), a newer balanced crystalloid, is gaining popularity for use in the critically ill, including patients with burns. This popularity is partly due to the fact that PL theoretically offers a favorable metabolic profile, but may also be attributed to its relatively lower cost. Patients who are critically ill with large burns receive enormous volumes of fluids, especially during the resuscitation period. The choice of balanced crystalloid solution used is likely to have an impact on the metabolic status of patients and their overall outcomes. The choice of fluid for burn resuscitation has been one of the most researched topics in burn care and various types of fluids have been superseded based on research findings. This narrative review examines the evidence guiding fluid management in burns and explores the data supporting the use of balanced crystalloid solutions, in particular PL for burn resuscitation. Our literature search revealed only one study that focused on a direct comparison between PL and standard Ringer's Lactate for burn resuscitation. Based on the limited literature on the use of PL in burns, it is difficult to draw meaningful conclusions. Further research, into the suitability of PL for use in burns, is needed before formulary changes are instituted widely.

Ten-Year Analysis of Bacterial Colonisation and Outcomes of Major Burn Patients with a Focus on Pseudomonas aeruginosa.

A retrospective descriptive study included patients admitted with severe burns over the course of 10 years (2008-2018). Across all patients, there were 39 different species of bacteria, with 23 species being Gram-negative and 16 being Gram-positive bacteria, with also five different species of fungi cultured. Pseudomonas aeruginosa was the most commonly isolated organism, with 57.45% of patients having a positive culture. There was a significant difference in the number of P. aeruginosa isolated from patients that acquired their burns at work, in a garden, inside a vehicle, in a garage or in a public place. In patients that were positive for P. aeruginosa, the number of operations was higher (2.4) and the length of stay was significantly increased (80.1 days). Patients that suffered from substance abuse demonstrated significantly higher numbers of isolated P. aeruginosa (14.8%). Patients that suffered from both mental health illness and substance abuse demonstrated significantly higher numbers of P. aeruginosa isolated (18.5%). In the P. aeruginosa-negative group, there were significantly fewer patients that had been involved in a clothing fire. Furthermore, in the P. aeruginosa-negative patient cohort, the mortality rate was significantly higher (p = 0.002). Since the incidence of P. aeruginosa was also associated with a decreased mortality rate, it may be that patients admitted to hospital for shorter periods of time were less likely to be colonised with P. aeruginosa. This study demonstrates novel factors that may increase the incidence of P. aeruginosa isolated from burn patients.

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries.

BACKGROUND: Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation. METHODS: In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk. RESULTS: A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed. CONCLUSIONS: In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

Augmented Reality-Assisted Design of Local Flaps: A New Practical and Educational Tool in the Field of Plastic Surgery.

ABSTRACT: Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

Recommendations for Influenza Vaccination in Burns Patients Based on a Systematic Review of the Evidence.

Severe burn injury is a serious systemic insult that can lead to life-threatening secondary infections. Immunosuppression, inhalation injury, and prolonged length of hospital stay are factors that predispose patients to severe respiratory tract infections. Furthermore, evidence shows that burns can put one at risk of infection long after the original injury. Currently in the United Kingdom, the annual National Flu Immunisation programme outlines guidance for groups who are deemed high risk and, therefore, eligible for the influenza vaccine. At present, no guidance exists for the administration of the influenza vaccine in burn-injured patients, despite knowledge of immunosuppression. The aim of this literature review is to examine the evidence for associations between burn injury and influenza and, where available, evaluate efficacy of influenza vaccines in this cohort. In addition, literature was searched for the effectiveness of the influenza vaccine in patients 65 years and above and in patients admitted to the intensive care unit (ICU), two domains common to patients with severe burns. Three papers were found to suggest increased susceptibility to influenza following burn injury; however, no papers studying the effectiveness of the influenza vaccine in this group were found. Several studies demonstrated improved outcomes in patients over 65 years and patients admitted to ICU. Following the evaluation of the evidence, this review advocates for the consideration of hospitalized burn patients for the influenza vaccine. We suggest the avoidance of vaccine administration in the acute burn phase. Further prospective clinical trials would be required to validate these findings.

Perspectives From a Regional Plastic Surgery Centre on Evidence for the Purported Link Between SGLT2 Inhibitors and Fournier's Gangrene.

Introduction: The recent report issued by the MHRA indicating an association of Sodium glucose linked transporter type 2 (SGLT2) Inhibitors with the contraction of Fournier's Gangrene (FG), has been drawn with insufficient supporting evidence and without an adequately powered study to make any meaningful assertions or recommendations. We aimed to look specifically at the currently available dataset used to link SGLT2 Inhibitors to FG and highlight what conclusions or inferences can meaningfully be made, in particular the power of any study that would be required to make sensible conclusions. Methods: World literature review of SGLT2 Inhibitors and FG was performed. With a subsequent 10-year review of cases of FG seen in a regional burns and plastics centre. Data was collected retrospectively from the coding department at Whiston Hospital for all patients with necrotising fasciitis. An electronic document management system was used to identify patients with FG specifically as well as their diabetes state and medication history. Results: Seventy-eight patients were admitted with FG, of whom 32 had diabetes mellitus (DM). Of those with DM none was taking an SGLT2 Inhibitor, 17 patients were taking metformin, a further nine patients were taking a second line medication and 14 required insulin injections. Discussions: DM is a known major risk factor for FG, which is clearly observed in our patient cohort. The risk of patients with DM developing FG is irrespective of the medication patients are taking. The current articles and reports published have little ground to claim an association between SGLT2 Inhibitors and FG and are missing the crucial message that needs to be conveyed to the public: that DM is a major risk factor for FG and patients suffering with diabetes need to be extra vigilant.

Photodynamic antimicrobial chemotherapy coupled with the use of the photosensitizers methylene blue and temoporfin as a potential novel treatment for Staphylococcus aureus in burn infections.

Photodynamic antimicrobial chemotherapy (PACT) is a novel alternative antimicrobial therapy that elicits a broad mechanism of action and therefore has a low probability of generating resistance. Such properties make PACT ideally suited for utilization in localized applications such as burn wounds. The aim of this study was to determine the antimicrobial activity of MB and temoporfin against both a S. aureus isolate and a P. aeruginosa isolate in light (640 nm) and dark conditions at a range of time points (0-20 min). A Staphylococcus aureus isolate and a Pseudomonas aeruginosa isolate were treated in vitro with methylene blue (MB) and temoporfin under different conditions following exposure to light at 640 nm and in no-light (dark) conditions. Bacterial cell viability [colony-forming units (c.f.u.) ml-1] was then calculated. Against P. aeruginosa , when MB was used as the photosensitizer, no phototoxic effect was observed in either light or dark conditions. After treatment with temoporfin, a reduction of less than one log (7.00×107 c.f.u. ml-1) was observed in the light after 20 min of exposure. However, temoporfin completely eradicated S. aureus in both light and dark conditions after 1 min (where a seven log reduction in c.f.u. ml-1 was observed). Methylene blue resulted in a loss of S. aureus viability, with a two log reduction in bacterial viability (c.f.u. ml-1) reported in both light and dark conditions after 20 min exposure time. Temoporfin demonstrated greater antimicrobial efficacy than MB against both the S. aureus and P. aeruginosa isolates tested. At 12.5 µM temoporfin resulted in complete eradication of S. aureus . In light of this study, further research into the validity of PACT, coupled with the photosensitizers (such as temoporfin), should be conducted in order to potentially develop alternative antimicrobial treatment regimes for burn wounds.

Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature.

INTRODUCTION: Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS: An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION: The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS: More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

A Rule of Thumb for Hand Burns: Categorization and Mapping of Proportional Surface Area Involvement.

Hand burns are common and often complex injuries, requiring referral to specialist centers. The patient's thumbprint is a rapid means of accurately assessing hand burn surface area. This study aimed to establish categories and evaluate sites of hand burn surface area in order to facilitate comparison of hand burns. Sixteen burns involving the hand and wrist among 14 patients referred to a burns center were retrospectively categorized by burn mechanism, burn thickness, and hand burn surface area. The burn surface area in the clinical record was compared with that calculated by the thumbprint method and the rule of thumb diagram. Burn surface area in the clinical record was either "1%" or "<1%" in 9 of 16 cases. In contrast, the surface area was <1 thumbprint (T) in six burns, two were between 1 and 5T, three were 5 to 10T, two were 10 to 20T, two were 20 to 50T, and one was greater than 50T. The median thumbprint burn surface area was 1.5T (range 0.20-80T), which corresponds to 0.05% TBSA. The hand areas with the highest burn frequency per unit area were the dorsum of the hand and dorsum of the index finger, with relative sparing of the palm and palmar surface of the digits. Hand burns surface area varies widely, and thumbprint evaluation with categories and mapping allows finer distinction between the surface area proportions and specific sites involved, even in a small series of hand burns.

Is the use of a powered dermatome an aerosol-generating procedure (AGP)? Implications for personal protection against COVID-19 virus.

INTRODUCTION: Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol. METHODS: We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated. RESULTS: The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray. CONCLUSION: Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area. LAY SUMMARY: A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Data from national media reports of 'Acid attacks' in England: A new piece in the Jigsaw.

INTRODUCTION: There has been considerable concern in the UK with what seems to have been an increase in so-called 'Acid Attacks'. The key data sources (Police data, Hospital admissions and Burns unit data) have limitations in capturing the acid attacks comprehensively. Incidents not reported to the police are missed in the Police data. The more serious injuries are included in the hospital admissions data, with no information on people with less severe injuries, not accessing health care. Burns unit data reveals detailed information on the burns treatment but represents only a small percent of all the acid attacks. Our aim was to explore the role of media reports as an additional data source. METHODS: Data was obtained from the public domain using generic online search engines along with a formal medical literature review. Search parameters included any news articles on 'Acid Attacks' printed between 01/01/2016 and 31/12/2017 in England and Articles in National Press only. We compared the data from media reports to the only other data sources available on these crimes which were (a) Crime statistics from police (b) the proportion treated in hospital (c) the subgroup treated in the burns service in the highest incidence location in the UK. RESULTS: Two hundred and Thirty media articles in total were found in the preliminary search. Following the application of the exclusion criteria, sixty attacks were analysed. The demographic data, the geographic data were obtained from the articles and the results were analysed using Microsoft Excel. There were a total of 118 survivors with an average age of 29.5 years and a male to female ratio of 5.1:1. There were no reported deaths. In the assailants group, the average age was 21.6 years with a male to female ratio of 15.7:1. All the data sources revealed higher male survivor predominance. The average age of the survivors was similar in the media reports, police data and the Burns centre data and was higher in the hospital data. Information on assailants and motives, available only on media reports and police data, corroborated well with each other. Media reports gave further information on the circumstances of the incident, the location and the number of survivors per assault, which was not available on any other data source. Though there was a rise in chemical assaults reported in media reports and MPS data in 2017 compared to the previous year, there was no rise in chemical assault related hospital admissions. CONCLUSION: The majority of the survivors were males, which is consistent between all UK data sources. Media reports revealed that the South east of England had the majority of chemical assaults in England. Data from this source provides a further piece in the jigsaw especially in relation to the circumstances, the geographic location of the chemical assault and number of survivors per incident. We acknowledge the limitations of media reporting. In the absence of a formal database for such injuries and incomplete data from various sources, we have to consider all possible data sources to provide new information. We have discussed the utility, pros & cons of media reports as one of the additional sources of information to better understand these injuries.

Identifying patient concerns during consultations in tertiary burns services: development of the Adult Burns Patient Concerns Inventory.

OBJECTIVES: Identifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients. DESIGN: Content for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey. SETTING: Within outpatient secondary care. PARTICIPANTS: Twelve adult burns patients and MDT members from two regional burns centres. RESULTS: A total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items). CONCLUSIONS: The Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter.

Hand burns surface area: A rule of thumb.

INTRODUCTION: Rapid estimation of acute hand burns is important for communication, standardisation of assessment, rehabilitation and research. Use of an individual's own thumbprint area as a fraction of their total hand surface area was evaluated to assess potential utility in hand burn evaluation. MATERIALS AND METHODS: Ten health professionals used an ink-covered dominant thumb pulp to cover the surfaces of their own non-dominant hand using the contralateral thumb. Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method, and thumbprint ellipse area calculated to assess correlation. RESULTS: Mean estimated total hand surface area was 390.0cm2±SD 51.5 (328.3-469.0), mean thumbprint ellipse area was 5.5cm2±SD 1.3 (3.7-8.4), and mean estimated print number was 73.5±SD 11.0 (range 53.1-87.8, 95% CI 6.8). The mean observed number of thumbprints on one hand was 80.1±SD 5.9 (range 70.0-88.0, 95% CI 3.7), χ2=0.009. The combined mean of digital prints was 42, comprising a mean of two prints each on volar, dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar prints were 15 (11-19), dorsal 15 (11-19), ulnar palm border 3, first web space 2, and second, third and fourth web spaces one each. Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the area of one thumbprint was approximated as 1/30th of 1%. CONCLUSIONS: We have demonstrated how thumbprint area serves as a simple method for evaluating hand burn surface area.