Ela J. Hyland

Prospective, randomised controlled trial comparing Versajet™ hydrosurgery and conventional debridement of partial thickness paediatric burns☆

INTRODUCTION Conventional surgical debridement of burn wounds consists of tangential excision of eschar using a knife or dermabrasion until viable dermis or punctate bleeding occurs. The Versajet™ (Smith and Nephew, St. Petersburg, FL, USA) hydrosurgery system has also been advocated for burn wound debridement, with the suggestion that enhanced preservation of dermal tissue might reduce subsequent scarring. METHODS A prospective randomised controlled trial was undertaken comparing Versajet™ to conventional debridement. After excluding those with facial burns, 61 children ≤16 years of age undergoing debridement and skin grafting for partial thickness burns were recruited. Adequacy of debridement was assessed by 2mm punch biopsies taken pre- and post-debridement. Surgical time, percentage graft take at day 10, time to healing, post-operative infection and scarring at 3 and 6 months were assessed. RESULTS Thirty-one children underwent conventional debridement and 30 debridement using Versajet™. There was a significant difference in the amount of viable dermal preservation between the two groups (p=0.02), with more viable tissue lost in the conventional group (median 325 μm) versus the Versajet™ group (median 35 μm). There was no significant difference between graft take at day 10 (p=0.9), post-operative wound infection (p=0.5), duration of surgery (p=0.6) or time to healing after grafting (p=0.6). Despite better dermal preservation in the Versajet™ group, there was no significant difference between scarring at 3 or 6 months (p=1.0, 0.1). CONCLUSIONS These findings suggest that Versajet™ hydrosurgery appears a more precise method of burn wound debridement. Although dermal preservation may be a factor in reducing subsequent hypertrophic scarring, there were no significant differences found between scarring at 3 or 6 months after-injury.

Rural and metropolitan pediatric burns in New South Wales and the Australian Capital Territory: does distance make a difference?

To determine if differences exist between children who sustain burns in rural areas and in metropolitan areas, an analysis of children presenting to the Burns Unit at The Children’s Hospital at Westmead, from the January 1, 2008 to December 31, 2012 was performed. In all, 4326 children met the inclusion criteria, of which 21.2% came from rural regions. Just more than a quarter (26.0%) of rural children and 11.6% from metropolitan areas were Indigenous Australian (P < 0.0001). The average age of rural child was 4.5 years; metropolitan child was 3.9 years (P = 0.0001). Boys were more likely to sustain burns in both populations. Of the rural children, 40.8% sustained contact burns, 37.7% scald, and 12.5% flame. In contrast, 58.8% metropolitan children sustained scalds, 27.4% contact, and 4.5% flame. The home was the most common place for all burns to occur, but rural injuries commonly occurred outdoors. Burns were associated with risk-taking behavior in 15.3% rural and 8.7% metropolitan children (P < 0.0001). Nearly two thirds (65.9%) of children in both groups received adequate first aid (20 minutes of cool running water). Major burn injuries (≥10% Total BSA) occurred in 3.4% of rural and 2.1% metropolitan children (P = 0.02). Skin grafting was required in 28.3% rural and 16.3% metropolitan children (P = 0.0001). Nearly 32% of rural children required admission to the Burns Unit for >24 hours (15.9% metropolitan; P = 0.0001). Significant differences exist between burns sustained by rural and metropolitan children. This should be accounted for in burns prevention campaigns and the education of local health practitioners.

An assessment of early Child Life Therapy pain and anxiety management: A prospective randomised controlled trial ☆ ☆☆

INTRODUCTION Burns remain extremely painful and distressing in young children. The consequences of poorly managed pain and anxiety can be life-long. Whilst Child Life Therapy (CLT) has been shown to be effective in many situations, few studies have looked at the effectiveness of CLT in regard to reducing pain and anxiety in children undergoing burn dressing changes. METHODS A prospective, randomised controlled trial was conducted, comparing CLT versus standard care in relation to pain and anxiety scores of children undergoing their initial burn dressing change. Pain and anxiety were assessed by an independent observer and questionnaires completed by the child, parent/caregiver and nursing staff. RESULTS 50 subjects were recruited in each treatment group; median age 2.3 years (CLT) and 2.2 years (standard care). The median total body surface area (TBSA) burnt was 0.8% (CLT) and 0.5% (standard care). The majority were partial thickness dermal burns (88% CLT, 94% standard care). Rates of parent anxiety and pre-procedural child pain and anxiety were similar. Combined and scaled pain and anxiety scores in the CLT group were significantly less than in the standard treatment group (p=0.03). Whilst pain was significantly better in the CLT group (p=0.02), fear scores, wound outcomes and the need for skin grafting were not statistically different in either group. CONCLUSIONS The presence of a Child Life Therapist, with their ability to adapt to the environment, the child and their family, significantly reduced the experience of pain during paediatric burn dressings.

Pediatric burns research: A history or an evolution?

BACKGROUND/PURPOSE Pediatric burns research has increasingly been recognized as a sub-specialty of its own. The aim of this study was to assess and analyze the publication patterns of the pediatric burns literature over the last six decades. METHODS A search strategy for the Web of Science database was designed for pediatric burns publications, with output analyzed between two periods: 1945-1999 (period 1) and 2000-2013 (period 2). RESULTS There were 1133 and 1194 publications for periods 1 (1945-1999) and 2 (2000-2013), respectively. The mean citation counts of the top 50 publications were 77 (range 45-278) and 49 (range 33-145) for periods 1 and 2, respectively. There were 26 and 20 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Of these there are two authors that have published 47 papers in both combined time-periods. There were 29 and 9 journals that have published 50% of the publications for time-period 1 and 2 respectively. In period 2, there were two burns journals that have published 37.2% of the total articles. CONCLUSIONS Pediatric burns research has evolved from an associated, dispersed entity into a consolidated sub-specialty that has been successfully integrated into mainstream burns journals.

Have we really decreased mortality due to severe burn injury in children

In developed countries, in the twenty-first century, severe, large total body surface area (TBSA) burn injuries in children are rare. Prevention campaigns, education and public health interventions have significantly decreased the number of children sustaining burn injuries as well as the severity of such injuries. Many technological medical and surgical advances have been developed in burn care over the past several decades, increasing survival. Despite these interventions, long-term survival post burn injury may still be significantly reduced.

Biobrane™ and skin staples: beware of necrotic ulceration

Biobrane™ is a product used for temporary wound coverage post major paediatric burn wound debridement. We report two cases of necrotic ulceration associated with the use of Biobrane™ with skin staples. We suggest securing Biobrane™ with alternatives such as adhesive tapes and glue to prevent the occurrence of this adverse outcome.

Management and outcomes of children with severe burns in New South Wales: 1995-2013

As a result of improvements in injury prevention, severe burns appear increasingly uncommon in Australian children. Such injuries continue to have devastating impacts, with major consequences for the patient, their family, treating clinicians and the caring institution.

Airway compromise in children with anterior neck burns: Beware the scalded child.

The aim of the study was to describe characteristics of children with anterior neck burns admitted to our Paediatric Intensive Care Unit (PICU) and to highlight potential airway complications associated with these injuries, especially in children with scalds.