Quentin Frew

Burn injury to a reconstructed breast via a hot water bottle

Breast reconstruction following mastectomy for breast cancer has become an almost routine procedure within the United Kingdom. A number of autologous tissue flaps have been described including the latissimus dorsi (LD), transverse rectus abdominis myocutaneous (TRAM) and DIEP flap. The DIEP has now become the flap of choice for breast reconstruction as it does not involve harvest of rectus muscle hence maintaining abdominal strength and reducing the risk of abdominal herniation. It is also less painful postoperatively and has a shorter recovery phase. However, flap elevation usually results in transection of nerves responsible for cutaneous sensation and thermoregulatory function which may increase the risk of accidental thermal damage. A fit and well 76 year old lady who had a failed immediate implant reconstruction of her right breast underwent a delayed DIEP reconstruction approximately 12 months post-mastectomy. Three months post-procedure she used a hot water bottle wrapped up in a towel to relieve back pain. Unfortunately, she fell asleep with the bottle, waking up later on to find it on her chest. There were no immediate indications of a burn injury, however later on in the day she noted increased redness and blistering over the surface of the flap. This was initially managed conservatively by her GP. However, as the wound failed to heal and in fact appeared to expand, she was referred to our unit 3 weeks later. She had a clearly defined well circumscribed adherent layer of eschar over the flap (Figure 1). The patient had suffered a full thickness burn to her DIEP flap with the resulting wound measuring approximately 6 7 cm in size. The burn was debrided and a split skin graft applied soon after presentation. The graft took well and the wound healed completely within 2 weeks (Figure 2). This is the first report of a burn injury to a DIEP flap from a hot water bottle. The potential for hot water bottles to

Smoke inhalation increases intensive care requirements and morbidity in paediatric burns

Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burns intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.

The Hand Burn Severity (HABS) score: A simple tool for stratifying severity of hand burns

Hand burns represent a unique challenge to the burns team due to the intricate structure and unrivalled functional importance of the hand. The initial assessment and prognosis relies on consideration of the specific site involved as well as depth of the burn. We created a simple severity score that could be used by referring non-specialists and researchers alike. The Hand Burn Severity (HABS) score stratifies hand burns according to severity with a numerical value of between 0 (no burn) and 18 (most severe) per hand. Three independent assessors scored the photographs of 121 burned hands of 106 adult and paediatric patients, demonstrating excellent inter-rater reliability (r=0.91, p<0.0001 on testing with Lins correlation coefficient). A significant relationship was shown between the HABS score and a reliable binary outcome of the requirement for surgical excision on Mann-Whitney U testing (U=152; Z=9.8; p=0.0001). A receiver operator characteristic (ROC) curve analysis found a cut off score of 5.5, indicating that those with a HABS score below 6 did not require an operation, whereas those with a score above 6 did. The HABS score was shown to be more sensitive and specific that assessment of burn depth alone. The HABS score is a simple to use tool to stratify severity at initial presentation of hand burns which will be useful when referring, and when reporting outcomes.

Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients.

Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.

Use of biobrane® to dress split-thickness skin graft adjacent to skin graft donor sites or partial-thickness burns.

Biobrane® (Smith & Nephew Wound Management, Hull, United Kingdom) is a flexible biosynthetic wound dressing that has been widely used to dress partial-thickness burns and donor sites of split-thickness skin grafts (SSG).1–3 We reported 11 cases from March 2008 to March 2012 in which Biobrane was used to dress SSG, where the grafted areas were adjacent to donor sites or partial-thickness burns. Biobrane was used to dress SSG and their adjacent donor sites in five cases. In the other six described cases, we used Biobrane in mixed-depth burns. After tangential excision and skin grafting the deep burns, Biobrane was used to dress the SSG and adjacent superficial partial-thickness burns. Nine of the 11 cases were children. Biobrane was used to cover SSG over scalp, forehead, arms, legs, dorsum of foot, and abdomen. It was fixed with staples. An outer absorbent dressing was applied for 2 days, then Biobrane was left exposed (Figure 1). After removal of staples, Biobrane came off the sheet grafts on day 5 and it peeled off the meshed grafts, superficial burnt areas, and donor sites on days 10 to 14. In all reported cases, SSG fully took without complications, and patients were comfortable. Biobrane applied over SSG on flat and convex body surfaces promoted adherence of the SSG to the wound, prevented shearing, and allowed fluid drainage. Its transparency allowed regular checking without disrupting the graft, and at the same time facilitated healing of the adjacent donor sites or partial-thickness burns. In all cases, Biobrane was our first choice to dress the partial-thickness burns or SSG donor sites. By using the same dressing to cover the adjacent SSG, we negated the extra theater time needed when using different dressings; therefore, this method is cost-effective.

Microvascular free tissue transfer in acute and secondary burn reconstruction

INTRODUCTION The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit. MATERIALS AND METHODS All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival. RESULTS Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft. CONCLUSIONS Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.

The use of Emla® cream to remove staples from skin-grafted areas.

Emla® cream 5% (AstraZenica UK Limited, Luton, United Kingdom) is a topical anesthetic agent containing 2.5% lidocaine and 2.5% prilocaine. In addition to its anesthetic effect, Emla® cream produces a biphasic vascular response with initial vasoconstriction, which reaches its maximum level after 90 minutes of application. After prolonged application (of more than 3 hours), vasodilatation occurs.1 Doses of up to 10 g of Emla® cream applied on leg ulcers result in plasma levels of lidocaine and prilocaine well below toxic levels.2 Emla® cream is used safely on open wounds.2,3 Staple fixation of split skin grafts is commonly used in plastic surgery due to the ease of use and the short time taken to secure the grafts. Removal of staples is often associated with discomfort and pain, and on occasion, removal is not tolerated well and becomes a prolonged process. Bleeding at the time of removal can obscure staples, which can result in the staples remaining in and becoming buried. We present the use of Emla® cream for the removal of staples from split-thickness skin-grafted areas in a patient who was on anticoagulant therapy. A 71-year-old man on warfarin sustained 6% TBSA to his right leg. Warfarin was stopped, and a therapeutic dose of Clexane® (Sanofi-Aventis, Surrey, United Kingdom) was given. Tangential excision and meshed split-thickness skin grafting were performed. After the surgery, warfarin was restarted in addition to Clexane®. On the sixth postoperative day, a wound check indicated that the graft had taken well. We applied a small amount of Emla® cream (a total of 5 g) over each of the staples. Then the wound was covered with cling film for 30 minutes. The patient was comfortable and reported no pain during removal of staples; no bleeding occurred (Figure 1). We believe that a topical application of Emla® cream to staples is simple, effective, offers good pain relief, and creates an environment that is pain-free and less stressful for the patient and the care team. The dual benefits of this cream, pain relief and vasoconstriction, facilitate the removal of all staples in one session in a timely manner.

The utility of microalbuminuria measurements in pediatric burn injuries in critical care

PURPOSE Microalbuminuria, as measured by urinary albumin-creatinine ratios (ACRs), has been shown to be a marker of systemic inflammation and an indicator of the potential severity of trauma and critical illness. Severe pediatric burns represent the best model in which to investigate the clinical utility of microalbuminuria. This study aims to ascertain whether ACR measurements have any role in predicting the severity or the intensive care requirements in the critically unwell pediatric burn population. MATERIALS AND METHODS A retrospective observational study was undertaken within a regional burn center with a dedicated 8-bed burn intensive care unit (ICU). This looked at 8 years of consecutive pediatric burns requiring intensive care support-a total of 63 patients after exclusions. Daily urinary ACR measurements were acquired from all patients. RESULTS All patients had greater than or equal to 1 ACR measurement out with the reference range, and only 8% (5/63) presented to the ICU with a normal ACR. The median day for the peak ACR measurement was day 4. The relative lack of mortalities (3/63) precluded adequate correlations between ACR and outcomes. Peak and mean ACR values correlate well with length of ICU stay, and the peak ACR also correlates with total length of hospital stay and severity of burn injury as measured by total body surface area burnt and number of organ systems requiring support. No significant differences were found when the patients were stratified by age. The peak ACR measurement was found to be independently predictive of the length of the ICU stay. As such, we have created a predictive model to prove that an ACR that remains less than 12 mg/mmol is predicative of an ICU stay of less than or equal to 7 days. CONCLUSIONS The clinical utilities of ACR measurements are demonstrated by their correlation with the severity of injury, length of ICU stay, and requirements for multiple organ support. Albumin-creatinine ratios raised over certain thresholds highlight to the clinician the need for closer observation and the potential deterioration of patients.

Burn Injuries Resulting from Hot Water Bottle Use: A Retrospective Review of Cases Presenting to a Regional Burns Unit in the United Kingdom

Introduction. Hot water bottles are commonly used to relieve pain and for warmth during the colder months of the year. However, they pose a risk of serious burn injuries. The aim of this study is to retrospectively review all burn injuries caused by hot water bottles presenting to our regional burns unit. Methods. Patients with burns injuries resulting from hot water bottle use were identified from our burns database between the periods of January 2004 and March 2013 and their cases notes reviewed retrospectively. Results. Identified cases involved 39 children (aged 17 years or younger) and 46 adults (aged 18 years or older). The majority of burns were scald injuries. The mean %TBSA was 3.07% (SD ± 3.40). Seven patients (8.24%) required debridement and skin grafting while 3 (3.60%) required debridement and application of Biobrane. One patient (1.18%) required local flap reconstruction. Spontaneous rupture accounted for 48.20% of injuries while accidental spilling and contact accounted for 33% and 18.80% of injuries, respectively. The mean time to heal was 28.87 days (SD ± 21.60). Conclusions. This study highlights the typical distribution of hot water bottle burns and the high rate of spontaneous rupture of hot water bottles, which have the potential for significant burn injuries.

A method of limb elevation during burn surgery

Elevation of limbs during burns surgery to access the posterior aspect is routinely required. We describe a method of limb holding during burns surgery using sharp towel clips fixed to the distal phalanges of a patients hands or feet. The limb is held in elevation using a sterile crepe bandage from the towel clips to a hook hung on a rail fixed to the theatre ceiling. We have used this technique for patients with extensive severe burns for many years with no significant damage to the nail beds or the tips of fingers and toes. This technique is convenient for surgeons as it allows easy access to hands and feet and the posterior aspects of arms and thighs. It is cost effective and safe as it spares an assistant and decreases the risk of potential occupational injury.Level of Evidence: Level V, therapeutic study.