Local Anaesthesia for Enzymatic Debridement of Cutaneous Burns: A Prospective Analysis of 27 Cases.

Enzymatic debridement (ED) is increasingly used for cutaneous burns. Compared with surgical debridement, ED has better preservation of viable dermis, less blood loss and autografting, however ED is painful. Current recommendations suggest local anaesthesia (LA) is useful for minor burns, but the evidence base is minimal. In our centre, we routinely use LA with good analgesic effect. This study was a single-centre, prospective analysis conducted at the Queen Victoria Hospital (UK). Patients had at least superficial partial thickness burns and received subcutaneous LA prior to ED during a 1-year period (October 2019-September 2020). Pain was assessed using a numeric scale of 1-10, recorded before, during and after the procedure. In total, 27 patients were included (n=17 males) with a median age of 47 (18-88 years). The mean total burn surface area was 1.5% (0.3-5.0). Treated sites included head and neck (1), trunk (5), upper limb (9) and lower limb (16). The most used LAwas bupivacaine 0.25% (n=25), followed by lidocaine 1% (n=2). Some required additional oral analgesia (n=8) or a regional blockade (n=2). Average pain score during debridement was 1.9 We have found LA effective, with favourable pain scores in comparison to previous studies with oral analgesia or regional blockade. LA is quick and easy to perform, as opposed to nerve blocks, which require trained personnel with ultrasound guidance. LA is a useful analgesic for patients with minor cutaneous burns undergoing ED. In some cases, it is sufficient without additional oral analgesia or regional blockade.

Le débridement enzymatique (DE) des brûlures est de plus en plus utilisé, ayant l'avantage d'être moins hémorragique et plus respectueux des tissus sains que la chirurgie, au prix d'une douleur plus importante. Les recommandations actuelles suggèrent l'utilisation de l'anesthésie locale (AL) sur les petites zones, avec un niveau de preuve minime. Dans notre centre, nous utilisons régulièrement l'AL, avec un bon effet analgésique. Cette étude a été conduite dans le CTB de l'hôpital Queen Vicoria (Royaume Uni). Durant 1 année (octobre 2019- septembre 2020), les patients devant bénéficier d'un DE recevaient préalablement une AL par infiltration. La douleur a été évaluée par échelle numérique (0 à 10) avant, pendant et après la procédure. Nous avons étudié 27 patients dont 17 hommes, d'âge médian 47 ans (18 à 88), brûlés en moyenne sur 1,5% (0,3 à 5), sur le cou (1), le tronc (5), le membre supérieur (9) et le membre supérieur (16). La bupivacaïne 0,25% a été la plus utilisée (25 fois), la lidocaïne 1% l'étant anecdotiquement (2 fois). Une analgésie complémentaire a été 10 fois nécessaire : orale 8 fois, régionale 2 fois. La douleur procédurale était cotée à 1,9 en moyenne. Nous estimons que l'AL est efficace, avec des scores de douleur favorables comparativement aux analgésies orale ou régionale. À la différence des analgésies régionales qui nécessitent un personnel entraîné et un écho- guidage, l'AL est facile et rapide. Elle peut être suffisante à elle seule pour le DE de brûlures minimes.

Accuracy of virtual assessment in hand trauma.

A virtual clinic was developed from an existing telemedicine system to manage hand trauma in the Queen Victoria Hospital, East Grinstead, UK, during the first wave of the COVID-19 pandemic. This study evaluates the accuracy of the assessments made and makes comparisons to the traditional face-to-face clinic. The accuracy of assessment was analysed by comparing diagnosis with findings at surgery. One hundred and eighty-nine virtual assessments conducted by telephone with photographic data or by video were compared to 129 face-to-face assessments conducted prior to the pandemic. There was no difference in the accuracy of virtual and face-to-face clinics for patients treated surgically (p=0.27); treatment was correctly predicted for 87% of the virtual group and 78% of the face-to-face group. However, fewer virtual assessments led to a surgical outcome (p=0.0064); 68% of the virtual group had surgical outcomes compared to 82% of the face-to-face group. Most face-to-face assessments were done by a specialty trainee compared to a range of clinicians in the virtual clinic. Accuracy of assessment among trainees was significantly associated with experience for the virtual (p=0.045) but not face-to-face clinics (p=0.94). Virtual assessment by video versus telephone plus photographs were similarly accurate. We conclude that virtual triage serves as a successful alternative to face-to-face appointments. It is robust and succeeds in reducing footfall to the hospital site in line with recent social distancing measures against COVID-19. We have shown that video conferencing triage is no better than telemedicine triage with telephone and photographs.

Dilemmas in the management of rhinophyma in pigmented individuals.

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV-VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

An assessment of histological margins and recurrence of completely excised cutaneous SCC.

There is a paucity of data relating to histological margins of cutaneous squamous cell carcinoma (cSCC) and local recurrence. Retrospective data were collected for 721 patients with cSCC treated at Queen Victoria Hospital, UK, and followed up for five years. The local recurrence rate was 6.1%, the mean time to recurrence was 12.61 months and 93% of recurrences occurred within two years. Sixty-six per cent of recurrences had a deep margin of 2.5 mm or less (p 0.041). The Pearson's correlation coefficient showed a strong correlation with tumour grade (r=0.82, p, 0.05), lymphovascular invasion (r=0.73. p<0.05), medium correlation with deep histological margin(r= -0.55, p<0.05), a weak correlation with male sex (r= 0.31, p<0.05) and the anatomical site of head and neck (r=0.31, p<0.05).The multiple regression analysis model using the 5 variables generated an r value of 0.71 and adjusted r square of 0.7. In conclusion, our findings are consistent with previously mentioned prognostic indicators and also demonstrate that deep histological margin is a significant predictor of local recurrence of cSCC. We recommend larger multi-institutional studies to confirm the above results to subsequently guide the specialist skin multidisciplinary teams' recommendations.

Consensus demonstrates four indicators needed to standardize burn wound infection reporting across trials in a single-country study (ICon-B study).

INTRODUCTION: Evidence-based interventions are needed to treat burn wound infection (BWI). Evidence syntheses have been limited by heterogeneity of indicators used to report BWI across trials. Consistent reporting of BWI would be facilitated by an agreed minimum set of indicators. The Infection Consensus in Burns study aimed to achieve expert consensus about a core indicator set (CIS) for BWI. METHODS: The CIS was established through development of a long list of BWI indicators identified from a systematic review and expert input. In a Delphi survey, UK expert participants rated the indicators according to use in everyday practice, importance for diagnosis and frequency of observation in patients with BWI. Indicators were included in the CIS if ≥75% of participants agreed it was important for diagnosis and used in everyday practice, and ≥50% of participants rated it as frequently observed in patients with BWI. RESULTS: One hundred and ninety-five indicators were identified from the systematic review and reduced to 29 survey items through merging of items with the same meaning. Seventy-five UK experts participated in the Delphi survey. Following a single survey round and a consensus meeting with an expert panel, four items were included in the CIS: pyrexia, spreading erythema, change in white cell count, and presence of pathogenic microbes. DISCUSSION AND CONCLUSIONS: To facilitate evidence synthesis, a single-country systematic, expert-informed approach was taken to develop a CIS to be reported consistently across trials reporting BWI as an outcome. Future work requires verification of the CIS with international experts.

Resuscitation tables: a useful tool in calculating pre-burns unit fluid requirements.

BACKGROUND: There is considerable variation in the standard of initial burn management, particularly burn surface area assessment and application of resuscitation formulae. Early aggressive management of major burns improves survival. Internationally, the Parkland formula employing lactated Ringer's solution is used for fluid resuscitation. This study aimed to assess whether Parkland fluid resuscitation tables could improve the accuracy of initial fluid requirement calculations. METHODS: The burn size had first to be determined for an adult and a child using a preshaded Lund and Browder chart. Fluid requirements then had to be calculated using the conventional Parkland formula. The burn size had to be similarly calculated for two further cases and fluid requirements calculated using resuscitation tables. The study had a sample size of 50, consisting of plastic surgery trainees, anaesthetists and burn nurse specialists. RESULTS: All the participants found the resuscitation tables to be quicker and easier to use. The burn size was correctly calculated in 72% of cases. Fluid resuscitation requirements were correct in only 55% when using the Parkland formula. The use of resuscitation tables improved the accuracy in calculating fluid requirements to 75%. CONCLUSIONS: The use of Parkland fluid resuscitation tables can improve accuracy and ease of calculation of fluid resuscitation requirements.

Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision.

INTRODUCTION: Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit. METHOD: Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed. RESULTS: The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%. CONCLUSION: After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Scrubbing brush decontamination--cement burn treatment.

Use of a pre-operative scrubbing brush to decontaminate cement burns is described. As cement particles are removed, further damage is prevented and patients derive great relief.

Median nerve contusion during endoscopic carpal tunnel release.

Median nerve contusion occurred in two patients treated by endoscopic carpal tunnel release. We discuss the possible cause of this complication and how to avoid it.

How would you like your tea, vicar?

INTRODUCTION: Scald injuries are the commonest cause of paediatric burns leading to hospital admission both in the United Kingdom (National Burn Care Review Committee Report; 2001) and around the world. The cost and significant morbidity resulting from scald injuries reiterates the need for effective prevention campaigns for primary caregivers. The majority of scalds in children occur in the kitchen (49%) at home. Three children a day under the age of 5 (1100/year) are involved in scalds resulting from pulling on a cup of beverage onto themselves. We therefore aim to study the temperature of common beverages made at home and their potential to cause significant thermal injury. MATERIALS AND METHODS: Common household beverages were formulated to assess the thermal characteristics. Each beverage was made in a standardized environment with constant ambient temperature of 22 degrees C. Beverages were made in 230 ml ceramic mugs, using boiled water from an electric kettle, instant coffee granules and teabags. Hot milk and hot water were prepared for comparison. Temperature readings were taken from 0 to 10 min. Cooling curves were then plotted. RESULTS: Milky beverages had the lowest starting temperatures (75-77 degrees C). Black tea and black coffee remained at temperatures greater than 65 degrees C despite cooling for 10 min. The addition of sugar did not alter the cooling rate. Similarly there was very little difference in cooling rates for skimmed and full fat milk. Addition of 10 ml rather than 5 ml of milk lowered the starting temperature and increased the cooling rates. DISCUSSION/CONCLUSION: Hot beverages can cause significant scald injuries especially in the paediatric population. We demonstrated the potential for a full thickness burn despite cooling for 10 min or the addition of cold milk. Thus the complacent attitude surrounding beverages under such conditions should be abolished. Our work also reiterates the need for education amongst caregivers regarding the handling of hot beverages in order to reduce the number of household injuries.

Potential subtherapeutic linezolid and meropenem antibiotic concentrations in a patient with severe burns and sepsis.

Altered pharmacokinetics in patients with major burns may result in serum antibiotic concentrations below those required to be effective against the common pathogens encountered in burns patients. The major changes in the fluid volumes of key body compartments, which occur with a large burn, may increase the apparent volume of distribution of a drug, thereby lowering its concentration when a standard dose is given. In addition, the observed increase in renal blood flow reported in burns patients, because of the change in cardiac output, may result in a higher drug clearance and a shorter elimination half-life. As a consequence, studies have recommended higher doses or more frequent dosing or both for some antibiotics in patients with major burns, but data are lacking for many of the antibiotics reserved for treatment of life-threatening infections. The authors measured serum concentrations of two antibiotics, linezolid and meropenem, in an immunosuppressed patient who presented with a severe burn to determine whether therapeutic concentrations were achieved, thereby improving the likelihood of infection control.