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.

A major burn injury in a liver transplant patient.

Immunosuppressive therapy may aggravate the clinical course of a burned patient, primarily affecting wound healing and thus complicating permanent wound coverage. We hereby present the successful management of a 48-year-old female liver transplant recipient with a major burn injury, aiming to elucidate the effects of the patient's immunosuppression on surgical treatment. After admission to the Burns ITU, the patient underwent serial debridement of the burn and coverage with cryopreserved allografts. Despite immunosuppression, no prolonged survival of the allo-epidermis was documented. Nevertheless, a variable degree of vascularized allo-dermis was clinically identified. She subsequently underwent skin autografting and was discharged home with most of the wounds healed. Although there are isolated reports of survival of skin allografts in immunocompromised patients, in our case the allografted skin did not provide permanent wound coverage. However, it permitted a staged surgical management, allowing the immunosuppressive regime to change, the skin donor sites to heal and it also provided a dermal scaffold for successful skin autografting.

Un traitement immunosuppresseur peut obérer l'évolution d'un brûlé, en raison de ses interactions avec la cicatrisation. Nous présentons la prise en charge couronnée de succès d'une patiente de 48 ans transplantée hépatique victime d'une brûlure grave, dans le but de faire le point sur la relation traitement chirurgical/chirurgie du brûlé au stade aigu. Après son admission en réanimation pour brûlés, la patiente a bénéficié de plusieurs séances d'excision/allogreffe. Malgré le traitement immunosuppresseur, les allogreffes ne sont pas restées en place plus longtemps. Cependant, une vascularisation, à un degré variable, de l'alloderme a été cliniquement observée. Elle a pu retourner à son domicile après autogreffes, les brûlures quasiment entièrement cicatrisées. Au contraire de quelques rapports d'intégration d'allogreffes chez des patients immunodéprimés, celles de notre patiente ont été rejetées. Elles ont toutefois tenu suffisamment longtemps pour permettre un changement de l'état immunitaire, la guérison des sites donneurs et le développement d'un sous-sol apte à recevoir les autogreffes.

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.

Treatment of nasal burns: analysis of 150 cases.

Nasal burns present a challenge for the plastic surgeon in terms of immediate management, choice of primary treatment and secondary reconstruction with the goals of good aesthetic and functional outcome. We present a retrospective analysis of the management of 150 patients with nasal burns treated in our center between July 2005 and July 2011. We rationalized our conservative and all surgical treatments of this subset of burns patients and organized them in a simple and structured way. The reconstructive options for most complex full thickness nasal injury is determined by the integrity of adjacent facial tissues which would always be preferred when available. Microsurgical free tissue transfer is dependent upon the fitness of the patient and the availability of unburned skin at the donor site. Secondary nasal reconstruction is based on an assessment of the residual functional and cosmetic problems. Airways narrowing from scar contracture or loss of support are managed using standard plastic surgical and rhinoplasty principles. Cosmetic refinements range from flap debulking to the importation of new tissue on to the nose. Our experience with this challenging group of patients has led us to develop a simple treatment algorithm for the management of nasal burns.

Les brûlures nasales présentent un défi pour le chirurgien plastique en terme de prise en charge immédiate, de traitement primaire ou de reconstruction avec un objectif de bon résultat esthétique et fonctionnel. Nous présentons une analyse rétrospective de 150 patients souffrant de brûlures nasales traités dans notre centre entre Juillet 2005 et Juillet 2011. Nous avons codifié nos traitements chirurgicaux d'une manière simple et structurée. Les options reconstructives dépendent de l'intégrité des tissus faciaux de voisinage qui seront toujours préférés s'ils sont disponibles. Le transfert microchirurgical libre dépend de la condition physique du patient et de la disponibilité d'une zone donneuse. Les reconstructions nasales secondaires dépendent de l'évaluation des séquelles fonctionnelles et esthétiques. Les sténoses en rapport avec le tissu cicatriciel ou la perte de support sous jacent sont soumises aux principes de la chirurgie plastique et de la rhinoplastie .Les améliorations cosmétiques vont du dégraissage des lambeaux au transfert de tissu. Notre expérience avec ce groupe de patients nous a conduit à développer un algorithme de traitement simple pour la prise en charge des brûlures nasales.

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.

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.

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 a frailty scoring system for burns in the elderly.

INTRODUCTION: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival. METHOD: Data from patients with burns greater than 10% and aged over 65 years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1-7) was assigned to each patient based on the records of their admission assessment. 42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9 years (range 65-95 years) survived (S) their ITU stay and of these, 83.3% survived at 1 year. 24 (57.2%) patients, mean age 78.4 years (range 66-95 years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10-85%) (P>0.05 using T Test) or inhalational injury (p>0.05 using Z test). Using Mann-Whitney U test analysis, the frailty score between the two groups showed a significant difference at p=0.0001 (Mann-Whitney U test=78), median=3 (S) and median=5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann-Whitney U test=111, p=0.02). CONCLUSION: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients.

Prognostic scoring systems in burns: a review.

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Comfort care in burns: the Burn Modified Liverpool Care Pathway (BM-LCP).

INTRODUCTION: Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS: A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS: There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION: The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

Estimating the usage of allograft in the treatment of major burns.

AIM: To assess the amount of allograft used in the past treatment of major burns and calculate a figure to guide estimation of the quantity of allograft required to treat future patients and aid resource planning. METHODS: A retrospective observational study. Records of 143 patients treated with major burns at a regional centre, from January 2004 to November 2008 were accessed with biometric data and quantity of allograft used being recorded. This data was used to calculate an allograft index (cm² allograft used/burn surface area (cm²)) (AI) for each patient. RESULTS: 112 of the 143 patients had complete sets of data, of the 112, 89 patients survived the initial stay in hospital. For all data average AI=1.077 ± 0.090. AI varied according to burn % area with burns < 40% requiring 0.490 cm² allo/cm²burn, increasing in a logarithmic fashion (R²=0.995) for burn areas > 40%. CONCLUSIONS: The ability to estimate deceased donor skin requirements based on % body surface area affected is important in the care planning for patients with major burns. Our findings of 0.5 cm² allograft/cm² burn for injuries less than 40% TBSA, increasing to 1.82 cm² allograft/cm² burn for injuries up to 80% TBSA can be used for planning purposes for individual services and for burn disaster planning.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit.

INTRODUCTION: 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD: All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS: 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION: The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Purpura fulminans skin loss: surgical management protocols at a regional burns centre.

SUMMARY: People with significant skin loss after sepsis frequently require skin grafting; as such, they are often referred to regional burns units for definitive soft-tissue cover. Such individuals have complex requirements after severe sepsis, and usually have complicated wounds. We have developed a protocol for managing these patients and their wounds within a high dependency, intensive-care unit, using allograft as an adjunct in preparing the tissue bed before autografting. This protocol includes optimisation of nutritional needs, microbiological surveillance and definitive soft tissue cover. We retrospectively reviewed all children referred over 18 months for management of skin and soft tissue loss after meningitis purpura fulminans. We reviewed the initial management of the septicaemia, associated co-morbidities, site and size of soft tissue defect, time to presentation for definitive skin cover, surgical procedure performed, timing of surgical intervention, and recovery of the patient's wounds. A total of six people (all children), with a mean age of 7 months (age range 4-21 years) were admitted to our unit between March 2004 and September 2005. Total percentage skin loss was 12% (6-20%). All of the children underwent debridement, received allograft to areas of skin loss and necrosis as a primary procedure, and subsequently underwent autograft. Two children required amputation of one or more limbs, and the stumps were covered with allograft followed by skin autograft. All patients had excellent autograft skin taken using this protocol.

Survival of a 75% burn in a patient with longstanding Addison's disease.

This is the first reported case of survival of a significant burn in a patient with established Addison's disease. The systemic stress response to thermal injury is well recognised, there is a marked hypermetabolic response with prolonged periods of catabolism. In particular, the elevation of plasma cortisol levels is crucial for this response to severe systemic stress. Cortisol elevation is maintained for the duration of burn wound healing, is proportional to the burned body surface area and the normal circadian rhythm of endogenous cortisol is lost. Acute adrenal insufficiency has been described in patients suffering major burn injuries with generally poor outcomes. We discuss the management and complications of adrenal replacement therapy in a severe burn setting, as illustrated by this case report.

The Soho nail bomb: the UCH experience. University College Hospital.

This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.

The removal of unwanted hair using a ruby laser.

A ruby laser has been developed to remove unwanted hair. Melanin within the hair is used as a natural chromophore. It is postulated that photothermal damage destroys the hair itself and also key cells surrounding the hair follicle to prevent regrowth. A prospective study of laser depilation in 116 patients or 175 sites was performed over a period of 18 months. All the patients had tried other methods of hair removal and found them to be unsatisfactory. Hair counts (follicles/cm2) were used to judge the outcome. The mean follow-up time was 23.25 weeks (range 12-76 weeks). After a mean number of treatments of 1.92 (range 1-20) there was a 56.4% reduction in hair density. Comparing pre- and post-treatment hair density, there was a highly significant reduction (paired t-test: P < 0.00001). Laser removal of hair is now a realistic treatment option.