Metin Nizamoglu

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.

Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilance and enforced legislation

Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately lower than the number of total cases at presentation. In an effort to better understand the legal considerations surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients. Lay Summary Burn injuries from corrosive substances can have fatal complications and leave survivors with severely debilitating physical injuries and psychological scars. The incidence of acid assaults appears to have increased in the UK and gained much publicity through widespread news coverage. This prompted us to look at our experience in managing patients who were victims of assault using corrosive substances. Over a 15-year period, we treated 21 people who sustained burn injuries as a result of an assault involving corrosive substances. Five people required hospital admission for the extent of their injuries and required significant burn reconstructive procedures. Interestingly, only nine out of 21 cases initiated a criminal investigation. Only two of the nine cases that initiated criminal investigations proceeded to indictment. In an effort to better understand legal considerations surrounding such assaults, we collaborated with lawyers experienced in this particular field and lay out for the first time the UK landscape of litigation in this complex area. We hope that our work will help educate healthcare professionals of the legal assistance and existing laws present to protect these vulnerable patients.

A challenging case of calcific myonecrosis of tibialis anterior and hallucis longus muscles with a chronic discharging wound

The occurrence of calcific myonecrosis of the anterior compartment of the leg is rare. Common risk factors include a history of trauma, although little is known about the exact pathophysiology, latency period or triggering factors resulting in disease progression. Macroscopically, it begins with a single muscle being replaced by a fusiform calcified mass, which progresses peripherally.

The management of acute peripheral arterial bleeding in emergencies: a plastic surgeon’s perspective

Sir, Peripheral arterial bleeding following trauma commonly presents to the emergency department. There is currently no national guideline for achieving haemostasis in the acute setting prior to definitive management. As plastic surgeons, we are often referred patients with uncontrolled bleeding in the accident and emergency (AE the other two said they would apply manual pressure without attempting to dress the wound. Twenty-two described a compression bandage comprising multiple layers of tight bandage around the wrist. The remaining nine described a point pressure dressing, using a solid object to focus the pressure of the bandage over the wound, such as a specimen lid or folded gauze placed over a non-adherent dressing over the wound. Twenty-one clinicians would apply manual pressure directly over the wound with or without a dressing. Surprisingly, only 14 mentioned elevation of the limb and 7 mentioned application of a tourniquet. Several other suggestions were made, such as underrunning the vessel with a suture, applying a surgical clip to the vessel or administering a local anaesthetic containing epinephrine. Although these suggestions can obtain haemostasis, it is preferable to stop bleeding without invasive measures that will potentially traumatise the vessel further endangering viable tissue for repair later, and this is only recommended as a last resort in order to preserve life. Often when faced with an acute traumatic arterial bleed, manual digital pressure is appropriate initially; however, this is impractical over prolonged periods and an appropriate dressing to control the bleeding is required until definitive surgical management is achieved. Rudge [1] et al. described using a specimen pot lid filled with cotton wool, placed over a non-adherent dressing over the wound and bandaged into position, with the bandage twisted over the lid to increase compression. We have also found this technique to be effective. Our management differed as we placed the lid flat side down and bandaged over the lid without twisting the bandage or filling the lid with cotton wool and still found this to be effective. In practice, the specimen lid can be interposed with anything that is relatively firm and can focus the compressive force over the desired point. This allows pressure to be localised to the desired point without compromising distal blood flowwhich commonly occurs with traditional tight bandaging. Our questionnaire identified elevation is not commonly implemented by over half of our cohort. This is easily rectifiable by educating and training staff. Furthermore, a tourniquet can be applied proximally to the wound to prevent blood loss if other methods fail. If provision allows, an improvised tourniquet can be made using a normal blood pressure cuff. This allows an easily applicable and controllable method of * Metin Nizamoglu mnizam@doctors.org.uk

Bubble bath burns: an unusual case

Abstract We present an unusual case of flash burn injury in an adolescent following accidental combination of foaming bath bubbles and tea light candle flame. There has not been any reported similar case described before. This serves as a learning point for public prevention and clinicians managing burn injuries.

The impact of major trauma network triage systems on patients with major burns

INTRODUCTION Trauma is a leading cause of death and disability worldwide. Patients presenting with severe trauma and burns benefit from specifically trained multidisciplinary teams. Regional trauma systems have shown improved outcomes for trauma patients. The aim of this study is to determine whether the development of major trauma systems have improved the management of patients with major burns. METHODS A retrospective study was performed over a four-year period reviewing all major burns in adults and children received at a regional burns centre in the UK before and after the implementation of the regional trauma systems and major trauma centres (MTC). Comparisons were drawn between three areas: (1) Patients presenting before the introduction of MTC and after the introduction of MTC. (2) Patients referred from MTC and non-MTC within the region, following the introduction of MTC. (3) Patients referred using the urban trauma protocol and the rural trauma protocol. RESULTS Following the introduction of regional trauma systems and major trauma centres (MTC), isolated burn patients seen at our regional burns centre did not show any significant improvement in transfer times, admission resuscitation parameters, organ dysfunction or survival when referred from a MTC compared to a non-MTC emergency department. There was also no significant difference in survival when comparing referrals from all hospitals pre and post establishment of the major trauma network. CONCLUSION No significant outcome benefit was demonstrated for burns patients referred via MTCs compared to non-MTCs. We suggest further research is needed to ascertain whether burns patients benefit from prolonged transfer times to a MTC compared to those seen at their local hospitals prior to transfer to a regional burns unit for further specialist care.

Recurrent Metastatic Melanoma Despite Multiple Surgical Interventions and Biological Targeted Therapy

A 40 year old Caucasian male was referred to our plastic surgery unit with a rapidly growing mass in his left groin. A biopsy was taken which showed the lesion was metastatic amelanotic melanoma. No primary was identified. He had a history of a halo naevus on his lower back that had fully regressed