Baljit Dheansa

The Management of Eyelid Burns

Eyelid involvement is common in facial burns. Ocular sequelae, including corneal ulceration, are usually preventable and secondary to the development of eyelid deformities, exposure keratopathy, and rarely, orbital compartment syndrome. Early ophthalmic review and prophylactic ocular lubrication is mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. Permanent visual impairment is rare with such prompt management. No binding aphorisms exist regarding the tissue used for eyelid reconstruction, with each case requiring an individual approach based on available skin. This review article covers the principles of ophthalmic management in addition to intermediate and long-term management of eyelid burns.

Progression of wound pH during the course of healing in burns.

The aim of this study was to measure the pH on the wound surface of 30 burn patients and test the hypothesis that wound surface pH is correlated to healing time and burn depth. Inclusion criteria were any adult outpatient with burn injury. Patient age was 17 to 75 years (mean, 44), burn depth ranged from superficial to full thickness with a TBSA of 0.4 to 4%. Cause of burn included scalds, flame burn, and contact burns. On admission, and at each dressing change, the pH on the wound surface was measured. The pH in both healing and nonhealing wounds was found to decrease with each dressing change. At the second dressing change, wounds that went on to heal were found to have a significantly lower pH of 7.32 in comparison with pH 7.73 in wounds that failed to heal and therefore required subsequent grafting (P = .004). Wound pH was also correlated to depth at the second dressing change (superficial = pH 6.05, full thickness = pH 8.0). The correlation between pH and wound outcome could be used as an additional diagnostic tool to predict poor healing in wounds. Early identification of a nonhealing wound may allow a more aggressive treatment regimen, including skin grafting, to bring about rapid wound healing.

Life-threatening coma and full-thickness sunburn in a patient treated with transdermal fentanyl patches: a case report

IntroductionFentanyl transdermal patches have been widely used in the treatment of chronic pain and in palliative care settings since 1991 in cases where prolonged opioid use is often necessary. Transdermal drug delivery is deemed safe and effective with the advantages of delivering a steady dose of the drug and improving patient compliance due to its ease of use. However, intentional and unintentional misuse and overdose using transdermal opioid patches has been widely reported in the literature.Case presentationWe describe the case of a 77-year-old Caucasian woman who developed severe opioid toxicity while sun tanning, likely due to altered fentanyl transdermal patch function in a heated environment. As a result of prolonged sun exposure due to an opioid-induced coma she then sustained hyperthermia and severe burns to her abdomen and lower limbs. This inadvertent fentanyl overdose necessitated initial treatment in intensive care and follow on care in a specialist burn unit.ConclusionPatients who are using fentanyl patches and their relatives should be educated about how to use the patch safely. Healthcare practitioners should warn patients about the possibility of overdosing on transdermally delivered drugs if used incorrectly. They should avoid strenuous activities and external heat sources such as warming blankets, hot water bottles, saunas, hot tubs or sunbathing and should seek medical attention if they develop a fever. Additionally, any burns sustained in the context of altered consciousness levels such as in this case with opioid overdose should raise suspicion about a potential deeper burn injury than is usually observed.

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.

Comparing outcomes of sheet grafting with 1:1 mesh grafting in patients with thermal burns: A randomized trial

BACKGROUND In many units, the standard mesh ratio is 1.5:1, but in our unit we have a 1:1 mesher, which does not expand the skin but provides regular fenestrations. There is some evidence that the unexpanded 1.5:1 meshed graft compares favourably with sheet grafts from a cosmetic perspective whilst reducing the risk of graft failure secondary to a subgraft haematoma, but none comparing the 1:1 meshed graft with the sheet graft. We conducted a randomized trial to compare surgical outcomes in unfenestrated sheet grafts with 1:1 meshed grafts. METHODS All patients aged ≥16 years undergoing skin grafts with either a sheet or a 1:1 mesh for burn reconstruction were included. Patients on steroids, those with conditions that impair healing, and burns >20% were excluded. Patients were randomized into the sheet grafting or mesh graft using a computer-generated allocation system. The mean percentage of graft loss was assessed by a Visitrak overlay system. At 3-4 months, 7-8 months and at 1 year, photos were taken for scar assessment using the Vancouver Scar Score (VSS). RESULTS Out of 72 patients, 48 patients (24 sheet vs. 24 mesh) completed the trial at 12 months. The mean age was 58 years (range 21-90). There was no total loss of graft in either group. The mean percentage of graft loss due to haematoma formation was higher in the sheet graft group (10%) compared to the 1:1 mesh group (6%) (P<0.062). The VSS score was 5 in both groups at 12 months. There was no significant difference in scar quality between the treatment groups. CONCLUSION These results show that the 1:1 mesh graft is superior to the sheet graft with regard to graft loss, although this result is not statistically significant. There are comparable findings in terms of cosmetic perspective at 12 months post-operatively in both arms of the trial.

Burns teaching in UK medical schools: Is it enough?

BACKGROUND Burns are frequently seen and managed in non-specialist settings. The crowding of the UK medical undergraduate curriculum may have resulted in the reduction of teaching on burns. AIM To determine the burns education experience and the level of competence among UK final year medical students in assessing and acutely managing patients with burns. METHODS An online questionnaire was circulated among UK final year medical students. RESULTS There was a total of 348 respondents. The majority of the respondents (70%) have not received any specific teaching on how to manage patients with burns. Nearly two-thirds of the students (66%) have never seen a patient being managed for burns throughout their training. Over 90% of respondents stated that they would not feel confident in initially managing a burn in the emergency department. The majority of the respondents (57%) have not heard of the criteria for referring a burns patient for further specialist management. There was almost universal agreement about the importance of knowing how to manage a burn initially. CONCLUSIONS There seems to be a lack of consistent undergraduate training in burns management and final year students lack the experience and knowledge to initially manage burns.

Should we be using silver based compounds for donor site dressing in thermal burns

f T n burns. We agree with them that a case report can give only imited information on clinical outcomes and that no definitive tatements on efficacy can be made, as we stated in our report. In contrast to some of the single-enzyme digestion ethods previously published, our cell isolation process nvolves two enzymes, dispase and trypsin, plus cell washing y centrifugation. We believe that this approach, with a focus n inclusion of the keratinocyte progenitors from the basal pidermal layer, may enable good results. As we also believe hat this method may be of interest to others in the field, we lected to submit a case report highlighting the two-step, cell ashing process, applied to a deep partial-thickness burn ound, in a clinical ambulatory setting. We consider this echnique an innovative approach to split-thickness skin rafting and only consider it in burn wounds that are deepermal, relatively large, and have not healed in 1–2 weeks. The published case report was the first performed at UPMC ercy Trauma and Burn Center. Since then we have treated 4 more patients with this approach. As we see satisfying linical results, we believe that we may be able to offer the herapy earlier and perhaps even to deeper burns. To this end, e are looking beyond autologous CK15+/alpha-6-integrin+ pidermal progenitors to the mesenchymal stroma cells (MSC) f the dermis. Currently, we have encouraging laboratory esults in the isolation of these cells together with the epidermal rogenitors in an on-site approach of isolation and cell grafting ithin 2 h. We hope to introduce this isolation combination in he near future. Such a combination, using a three-enzyme-step igestion that also involves collagenase, may enable a transiion to cell grafting of large, full-thickness wounds. In our view, his approach would best be tested in a larger, multi-center, ontrolled study and we would be open to any outside interest. gain, we agree with the authors; only such a study would give ufficient information on the effectiveness of such treatments. Jörg Gerlach and Alain Corcos

A novel technique of NexoBrid™ application to burns on the hands

The use of NexoBrid in the treatment of burns is increasing in the United Kingdom following recent publications that highlight the benefits of dermal preservation. Consequently, this is now thought to reduce skin grafting [1,2]. The use of Nexobrid may reduce the likelihood of a surgical procedure but it still needs specialist input that is particularly important for pain management [3]. We present a technique for effective Nexobrid application, an area that receives much less attention in the literature. Effective application of Nexobrid is clearly an important aspect to the treatment and there is much discussion between specialist units on the best approach to take. One of the issues relates to protection of the unburned skin surrounding the treated burn area. Vaseline is currently recommended, but other barriers such as Jelonet can be easier to apply. Our own experience suggests other approaches could also be helpful, such as using occlusive hydrocolloid dressings (e.g Duoderm) to minimise trauma to intact skin and provide an impermeable barrier for the duration of Nexobrid treatment. When Nexobrid is applied it is often a thick gel. It then becomes much less viscous and can result in leakage from the dressings. Many units use occlusive dressings [1,3,4] to contain the fluid, but in certain areas this may be challenging. Our approach for hand burns is simple. We use clear plastic gloves sealed at the wrist with tape to prevent leakage. This allows hand movement and direct observation whilst also being very easy to apply. By containing the Nexobrid we feel that we can gain maximal benefit by avoiding loss of the enzyme and reducing the complexity of the dressing. We feel that these small modifications have a significant impact on the effectiveness of Nexobrid and ultimately the aim of effective debridement with maximal dermal preservation. R E F E R E N C E S

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.

RE: Letter: A comparison of short-term surgical outcomes between NHS and private sector abdominoplasty surgery

Abdominoplasty has gained popularity in recent years among the British public – in a recent poll of 5000 women, 45 % stated that they would have cosmetic surgery if funds allowed. No studies have compared short-term surgical outcomes for abdominoplasty surgery between the NHS and the private sector in the UK. We investigated whether any transferable practices exist that could improve short-term outcomes in abdominoplasty. An NHS and a private cohort of patients were identified from the abdominoplasty caseload of a single surgeon and note made of demographic, intraoperative, and postoperative factors in order to permit statistical analysis of their surgical outcome. Hospital stay, number of surgeons, time to drain removal, and total drainage volume were significantly greater in the NHS cohort, while seroma rate and number of clinic visits were significantly greater in the private cohort. No statistical difference was detected in operative time, overall number of complications, and time to discharge from follow-up. Preoperative counseling of patients to expect a defined hospital stay can motivate them to achieve this.