Haemothorax: A potentially fatal complication of subclavian cannulation--A case report.

Central venous cannulation forms one of the mainstays of management of trauma and haemodynamically unstable patients. Frequently this procedure has to be done as an emergency in the emergency department. Ultrasound guidance has been recommended, especially for use by trainee members of the emergency department. We report a case of 44% full thickness burns with subclavian artery puncture due to a misplaced central venous catheter. This led to massive haemothorax, which eventually caused the patient to succumb. We re-emphasise the need for ultrasound guidance for insertion of central venous lines, especially in the emergency setting.

The impact of socio-economic deprivation on burn injury: A nine-year retrospective study of 6441 patients.

INTRODUCTION: Low socio-economic status is thought to be associated with increased burn risk, however the significance and generalisability across different populations and cultures has been questioned. METHODS: A nine-year retrospective study of burn presentations to a large teaching hospital (2005-2014) was performed to investigate the association between socio-economic status and burns. Demographic and injury data was collected via the trust 'Information portal'. The Welsh Index of Multiple: Deprivation 2011 was used to score for socio-economic status. Chi-squared test and Odds Ratios were calculated and statistical significance defined as p<0.05 throughout. RESULTS: 6441 burns were identified, with 755 (11.7%) admitted. Overall incidence rates were the highest published in the UK (0.35/1000/year) with sub group analysis showing the highest rates in under fives and males. Significant relationships between both age and burn mechanism and gender and burn mechanism (p=0.0005) were identified. Scald (67.1%) was the most common mechanism with the upper limb (48%) most commonly burned. Chi square analysis demonstrated a significant relationship between socio-economic deprivation, age and burn incidence (p≤0.0005), with a disproportionately high number of burns in patients under the age of 16 in the most deprived quintile (OR 1.23; 95% CI 1.06-1.44). CONCLUSION: This study specifically highlights patients under the age of 16 living in poorer socio-economic areas as the most at risk of suffering burns receiving hospital attention. This study demonstrates burns as a significant public health issue, and the results should aid in designing specific burn prevention strategies to target high-risk groups.

Reducing the burn risk to elderly persons living in residential care.

A 45-month retrospective analysis of 70 geriatric burn admissions to the Welsh Regional Burns and Plastics Unit highlighted 13 (18.6 per cent) injuries that occurred whilst the patient was in residential care (six residential care homes, seven nursing homes). The mean age overall was 83 years. The residential care patients had a TBSA of 12.5 per cent with a mortality of 46 per cent, whilst the group living in the community had a TBSA of 8.63 per cent with a mortality of 14 per cent. These results were not statistically comparable due to the unequal population grouping. The cause of injury in the residential group included five hot water scalds, six radiator contact burns, one flame burn and one flash burn. All 13 patients were found to have such severe dementia that they were unable to give a reliable history. In the majority of patients a lack of supervision was in part responsible. Some basic measures are presented that could reduce the incidence of accidental burn injury in this vulnerable group of the population.

Mr Muscle oven cleaner--is he too strong for us?

Mr Muscle is the proprietary name for a brand of household cleaning preparations produced by Bristol-Myers Co. Ltd of Uxbridge, Middlesex, UK. Recently manufacturing and marketing rights were purchased by Johnson Wax Ltd of Camberley, Surrey, part of S.C. Johnson and Son Inc. of Racine, Wisconsin, USA. The spray-on oven cleaner has been the causal link in a series of six deep dermal and full thickness skin burns admitted to the Welsh Regional Burns and Plastic Unit during the period January 1990 to July 1992. These patients will be discussed as a series of case reports. The constituents of the cleaner, its mode of action, packaging and presentation, together with regulations controlling its use will be discussed. Also a treatment regimen, with a plan of prevention for future burns, will be proposed. Information from the Johnson Wax group regarding recent revisions in the marketing of the product will also be presented.

Domestic central heating radiators: a cause for concern in all age groups.

A retrospective analysis of all burns admitted to the Welsh Regional Burns and Plastic Surgery Unit, Chepstow, in the period 1 January 1990 to 1 October 1993, highlighted a group of 50 patients who had sustained contact burns from the radiators of domestic central heating systems. There was a male prevalence, with an average age of 43.4 years (range 6 months to 100 years). The mean TBSA burned was 1.58 per cent (range 0.13-6.0 per cent) and half of the injuries were full thickness depth. The forearm and hand were predominantly injured. Although the literature has indicated that the incidence of contact burns peaks at the extremes of the age spectrum, this study has shown that contact radiator burns can be sustained by all age groups. The aim of the audit was to investigate the mechanism of injury and link precipitating factors. The contribution of the high surface temperature of the radiator to the burn injury is alluded to. The various methods available to reduce this risk are discussed and the use of the low surface temperature radiator, already routinely used in health care premises, is advocated.

Lime burns in a professional football goalkeeper - an unusual hazard.

Burns due to lime, although well reported as a result of occupational exposure, are uncommon in the sports arena. A case of such a chemical burn, which required surgery in a football goalkeeper is presented. There are safe alternatives to line marking on football pitches the use of which will prevent such injuries and avoid litigation.

Blood crossmatching for burn surgery: potential for reduced wastage using a modified dye formula.

Estimating the perioperative crossmatch requirement (CMR) of burn patients is difficult, as losses are variable and hard to predict. Accuracy is important, however, as over-provision risks wasting blood. Blood ordering tariffs have increased efficiency and reduced blood wastage in other branches of surgery. Dye has published a tariff for burn patients in the form of a formula, relating CMR to weight and percentage total body surface area (TBSA) excised. This study examines the efficiency of blood ordering and use among 72 burn patients and compares outcomes with the predictions of Dye's and a modified Dye's formula, for the same patients. All patients were crossmatched, but only 34 patients were transfused. The crossmatch:transfusion ratio was 2.1, with 52% of crossmatched blood being unused. Dye's formula would have reduced the total volume crossmatched for the same patients by 13%. The crossmatch:transfusion ratio would be 1.8, with 44% of cross-matched blood remaining unused. A modified form of Dye's formula was designed to reduce the high rate of blood non-use. This would reduce the total volume crossmatched by 40% and the rate of blood non-use to 20%. The crossmatch:transfusion ratio would be 1.24.

Isolated buttock burns: epidemiology and management.

This is a retrospective study of the epidemiology and management of isolated buttock burns presenting to the Welsh Regional Burns Centre from January 1996 to December 1999. A total of 36 cases have been treated of which 31 are included in this study. Approximately, 50% are in the paediatric age group and the sex distribution is equal for both adults and children. Contact burns form the largest group, and in children resulted in superficial burns requiring dressings only. The adult population is more likely to sustain deeper burns that require skin grafting, and approximately 50% will have a contributing premorbid condition. Despite difficulties in dressing and positioning of the patients, grafting of full thickness burns is appropriate without recourse to faecal diversion.

Electrical injury and the frequency of cardiac complications.

A retrospective review of the patients with electrical injuries admitted over a 5-year period was performed to establish the frequency of cardiac complications. There were 145 admissions during this time. A total of 128 (88 per cent) were low voltage injuries and 17 (12 per cent) were high voltage (> 1000 V) injuries. Of the 145 admissions, 104 (72 per cent) had a 12-lead electrocardiogram (ECG) recorded within 24 h of their injury. Of these patients, 73 (75 per cent) were then observed on a cardiac monitor for at least 24 h post-injury. Cardiac abnormalities were noted in four patients (3 per cent) during this period. Three patients had occasional ectopic beats which settled spontaneously over a 24 h period post-injury. The fourth patient developed atrial fibrillation (AF) after a high voltage injury which resolved following intravenous digoxin. Cardiac complications were more frequent in those who had experienced a loss of consciousness at the time of injury and in those who suffered a high voltage electrical injury. All of the patients with cardiac complications had these at the time of admission to hospital. This suggests that if there is no history of a loss of consciousness and the 12-lead ECG recorded on attendance at the hospital is normal, it is unlikely that the patient will go on to develop cardiac problems.

Free flap necrosis: a self-inflicted burn.

A report of a sequence of self-inflicted thermal injuries which affected the elbow joint and later the thermal necrosis of a reparative flap.

Paediatric friction hand injuries caused by domestic vacuum cleaners-a review from one unit.

The management of seven children with vacuum cleaner friction burns is described. Six of the children sustained full thickness burns. Four were treated operatively. Indications for surgery are outlined and important accident prevention strategies are highlighted.

Baby walkers--still a major cause of infant burns.

Baby walkers have been implicated in many forms of paediatric trauma, ranging from finger tip entrapment to severe head injury. Their relationship to childhood burns has been documented previously. The Department of Trade and Industry published further warnings in 1984 and the British Standards Institution in 1989. We wished to determine if the degree or frequency of thermal injury had been lessened by these recommendations. All parents of children under 15 months of age admitted to this unit in 1994 were asked if their child was in a baby walker at the time of injury. Eight of the 32 infants, aged between 6 and 12 months, were burned in their walking aid. Half of the burns were contact and half scalds, and the average in-patient stay was 8 days. One patient required formal resuscitation and three were grafted. The incidence and severity of thermal injury sustained in baby walkers remains at a high level despite increased safety measures. Perhaps it is time to concur with the American Academy of Paediatrics and recommend a ban on these dangerous aids.

Work-related burns in South Wales 1995-96.

The aim of this work was to evaluate the epidemiology of occupational burns referred to the Welsh Regional Burns Unit from 1st January 1995 to 31st December 1996. Three hundred and twenty-four patients were identified as having sustained occupational burns and the case notes of 319 were available for review. Data on age, sex, occupation, aetiology, percentage and site of burn, treatment, complications and length of hospital stay were recorded. Twenty percent of all burns referred to our unit occurred in the workplace, the majority of whom were male (male:female 11:1), with a mean age of 34 years. Patients presented late to our unit in 35% of cases, with an average delay of 5 days. Chemical burns predominated (23%), followed by flame (14%) and scald (14%). Small burns (< or =1% TBSA) were seen in 70% of all patients. Five patients had burns involving >15% TBSA. One hundred and seventy-five patients were admitted, of whom 79 required surgery. The length of stay ranged from 1-110 days (mean 8.5), with an average follow-up for all patients of 3.5 months. One patient died as a result of his burn injury. In conclusion, occupational burn injuries continue to account for a significant proportion of all burn injuries, affecting mainly young males in physical occupations. Despite Health and Safety guidance, chemical burns are the predominant cause and more needs to be done to educate those working with chemicals to prevent injury.

An arm elevating dressing.

An essential aspect of management of upper limb trauma (including burns), infection, and surgery, is elevation to reduce tissue swelling and to rest the injured part. Surgeons dealing with upper limb pathology each have their own method of elevating the arm. I wish to describe a type of arm elevating support which is used primarily for elevation of the upper limb postoperatively, but can be used as a sling in the ambulant patient.

Peripheral gangrene associated with fulminating meningococcal septicaemia. Is early escharotomy indicated?

We present a case of a 3-month-old boy presenting with fulminating meningococcal septicaemia associated with extensive peripheral gangrene requiring amputation of three limbs. The surgical management options and the role of early fasciotomy are discussed.

Does training reduce the incidence of industrial hand injuries?

The incidence of industrial hand injuries remains high despite the introduction of statutory measures and other advances in health and safety awareness. A prospective study was undertaken to determine if training before employment helps to reduce these injuries. A significant number of patients did not receive any training and this may have played a part in their injury but other contributory factors, such as human error, must also be taken into consideration. Some recommendations are made for future prevention.

Burn wound management in patients with epilepsy: adopting a multidisciplinary approach.

Many burns that occur following an epileptic seizure are deep due to prolonged contact with the thermal source. Primary care staff need to be aware of this and ready to refer patients to a burns unit.

The correction of scalp hair defects by tissue expansion.

This paper presents the results and complications in the correction of partial scalp alopecia in ten patients using the technique of 'tissue expansion'. The average size of defect that was covered by expanded hair bearing scalp was 45.9 cms2, and the largest defect covered measured 11 X 6 cm. This series indicates that tissue expansion is now one of the most promising methods available for dealing with the difficult problems of partial alopecia which can present to surgeons and physicians in a wide range of specialties.

Breast reconstruction by tissue expansion.

The techniques of tissue expansion for use in breast reconstruction is described, together with the results of its use in 33 patients. The advantages and disadvantages of tissue expansion in relation to other currently favoured techniques are discussed. It is concluded that tissue expansion represents a major advance in the field of breast reconstruction.

Following up the follow up--long-term complications in paediatric burns.

Paediatric burn follow-up optimally follows a balance between complication detection and avoiding unnecessary hospital visits. In a long-term review, we assessed complication patterns in children with burns requiring surgery. Using the Welsh Burns Centre database, a retrospective note review of paediatric burns over 3 years from 1995 was performed, identifying all children undergoing surgery for their burns. 94 patients were identified with a median follow-up since injury of 13.6 years. Mean age was 5.27 (SD=4.9) years. TBSA ranged from <1 to 70%. 94% underwent split-skin grafting. 18% (n=17) developed contractures and 33% (n=31) developed hypertrophic scarring. Those developing contractures were younger, and suffered significantly greater TBSA burns (p<0.05) than those developing hypertrophic scarring or those without complications. All contractures developed within 1-13 months, and hypertrophic scarring within 1-17 months. All patients sustaining axillary burns developed contractures, whilst 75% of contractures developed around the upper limb. In conclusion, younger patients with larger TBSA burns in the upper limb were at higher risk for contractures and hypertrophic scarring, which all presented within 18 months. Therefore any patients that are complication-free 18 months after-injury can be safely discharged, allowing streamlining of follow-up for the benefit of patients, parents and hospital resources.