S.Y Ying

An epidemiological study of 1063 hospitalized burn patients in a tertiary burns centre in Hong Kong.

A total of 1063 acute burn patients were admitted to the Burns Unit of Prince of Wales Hospital, Hong Kong between March 1993 and February 1999. There were 678 males and 385 females with a male to female ratio of 1.76:1. The median age was 13.1 year-old and the median burn size was 6% total body surface area (TBSA). Pediatric patients under the age of 15 year-old accounted for 550 (51.7%) admissions and 235 (42.7%) of them were toddlers <2 year-old, while adult patients of age above 15 year-old accounted for the other 513 (48.3%) admissions. There was no seasonal variation in admission. Domestic burns resulted in 756 (71.1%) injuries followed by industrial burns that caused 175 (16.5%) admissions. The median hospital stay was 9 days and 54 patients (5.1%) had inhalation injury requiring intubation and ventilatory support. Twenty-four patients died in this series which yielded a mortality rate of 2.3%. The median age for this mortality group was 46.6 year-olds with a median extent of burns of 68% TBSA. There were 16 males and 8 females with a male to female ratio of 2:1. Eighteen (75%) patients had flame burns and 15 (83.3%) of them had inhalation injury. The mortality group had significantly larger burn size (P<0.001), higher incidence of inhalation injury (P<0.001) and older age (P<0.001) compared to the survivors.

A study of burn injuries in the elderly in a regional burn centre

We evaluated the epidemiology and outcome of 94 elderly burn patients of age 60 years or older treated in a local burn centre over a period of 6 years. There were 44 males and 50 females with a male to female ratio of 0.88 and an average age of 73.8+/-9 years. The mean extent of burn was 13.3+/-18.4% total body surface area (TBSA) with 14 patients (15%) suffering from a burn size >20% TBSA. The vast majority of injuries (90%) occurred at home. Scalds resulted in 62 admissions (66%) and flame burns accounted for another 29 admissions (31%). The burns predominantly involved the extremities and the trunk. Four patients had inhalation injuries and required admission to the Intensive Care Unit for ventilatory support. The majority of patients (60%) did not require any operations. The mean hospital stay of the survivors was 30.1+/-34.1 days and 35% of them stayed less than 2 weeks. Fifty-five patients (59%) had at least one pre-existing medical problem requiring long-term medication and 41 patients (44%) were living alone. Sixty-three patients (67%) presented more than 8 h after the burn injuries and 34 patients (36.2%) had no first aid treatment of their burn wounds. In addition, 40 patients (42.5%) had their wounds treated inappropriately. Seven patients died in this series which yielded a mortality rate of 7.4%. The outcomes of early versus late excision and grafting were also analyzed.

Assault by burning--a reappraisal.

Assault by burning is a serious form of trauma that often results in higher incidence of inhalation injury, longer intensive care unit (ICU) and hospital stay, and higher mortality rate than is observed in the general burn population. We evaluated the epidemiology and outcome of assault burn victims treated in a tertiary burn center over a 6-year period. Among the 1063 acute burn patients who had been admitted to the Burns Unit between March 1993 and February 1999, 28 (2.6%) had assault burn injuries either by scald, chemical or fire. The mean extent of burn was 21.9%+/-20.8% (range 2-90%) total body surface area and the mean length of hospital stay was 65.2+/-107.3 days (range 1-565). Nineteen out of 25 patients (67.9%) underwent 76 operations. Nine patients had inhalation injuries requiring intubation and ICU admission. Three patients died in the series, which yielded a mortality rate of 10.7%. Compared to the general burn population, the assault burn group had significantly larger burn size (P<0.001), higher incidence of inhalation injury (P<0.001), longer ICU and hospital stay (P<0.001), and higher mortality rate (P<0.005). When these 28 victims were grouped according to the type of assault burn injury into a fire group, chemical group and scald group, all the 9 ICU admission and the 3 mortalities belonged to the fire group. Assault by fire resulted in larger burn size (P=0.03), more inhalation injury (P<0.001) and longer ICU stay (P=0.02). Although the fire group had a longer hospital stay and higher mortality rate, this was statistically insignificant.

Suicidal burns in Hong Kong Chinese

There were 1063 acute burn patients admitted to the Burns Unit of Prince of Wales Hospital, Hong Kong, between March 1993 and February 1999. Eleven patients (1%) were burned due to attempted suicide. Seven were males and four were females, with a male:female ratio of 1.75:1. The median age was 38 years (range: 20-49 years) and the median extent of the burns was 55% total body surface area (range: 1-95%). Ten patients (90.9%) were self-incinerated and one patient attempted suicide by jumping into a hot bath. Seven patients (63.6%) suffered from severe smoke inhalation injury that required immediate intubation for ventilatory support. The average number of operations for the survivors was 3.7 (range: 0-8) and their median hospital stay was 42 days (range: 2-92 days). Four patients (36.4%) died from their injuries. Suicidal burns were more common among unemployed males with a history of psychiatric illness and substance abuse. Town gas (naphtha: a mixture of 49% hydrogen, 28.5% methane, 19.5% carbon dioxide and 3.0% carbon monoxide) was the most frequently used agent for self-immolation because it is probably the most convenient source of a fire accelerant in Hong Kong. Compared to the general burn population, this suicide group had a larger extent of burns, higher incidence of inhalation injury, required more operative treatment and longer hospital stay with a higher mortality rate.

Playing with fire — a significant cause of burn injury in children

We report our experience with 50 patients who were burned as a result of playing with fire over the period of January 1993 to December 1999. There were 43 males and 7 females with a male to female ratio of 6.1:1. The average age was 12.3+/-10.3 year with 39 (78%) patients under the age of 15. The mean extent of burn was 6.4+/-10.7% total body surface area (TBSA) and 2 children had extensive burns >30%. The burns predominantly involved the head and neck region, upper limb, hand and lower limb. There was no mortality in our series. Wax and fireworks were recognized as the two major burn causing agents in these 50 patients. Risk factors associated with these injuries as well as preventive measures were also presented.

Before the paradigm shift: concepts and communication between doctors and nurses in a burns team

The evolution of care delivered by a multidisciplinary burns team is a function of the effectiveness of the professional communication between team members. In this exercise, we have explored concepts and communication between nurses and doctors in a burns team. Loosely structured weekly meetings were held over a 4-month period. The explicit objective was to determine and define the current model of burns care in a regional burn centre. The implicit objective, however, was to develop a mutual appreciation of actual and potential problems in communication. Consensus task identification was achieved at the end of each meeting with full compliance in completing the tasks before the next meeting. Although there was a unanimous commitment to the team concept, traditional, professional, paradigms persist. For nurses, the concept of holistic modelling predominated, whilst the disease centred paradigm remained the focus of medical modelling. Linguistic, cultural and professional barriers to effective communication were identified but did not readily conform to prior expectations. Experience in burns care can transcend these barriers more effectively than a common culture or profession. In conclusion, team work and team building is a complex process that can benefit from an ongoing process of re-evaluation. An obvious yet common error is to assume a level of mutual understanding that does not in fact exist. Stepping aside to re-explore fundamental principles on which team members base their personal and professional practice can help in elucidating and determining new paradigms of care, which can be evaluated and appropriately implemented. The consensus conclusion was that this approach was a very valuable investment in time in pursuing excellence in the field of burns care.

Iatrogenic burn caused by an alcohol lamp

Iatrogenic injury is an intrinsic risk of all medical procedures. Various kinds of iatrogenic complications have been extensively reported and recognized. Two patients were referred to the Prince of Wales Hospital for iatrogenic flame burn caused by the breakage of an alcohol lamp during ENT examination. They were 8 and 9 years old and sustained 12 and 17% intermediate to deep dermal burns respectively. There was no eye or inhalation injury. They were treated initially at the referring hospital. Despite having the best possible treatment, the parents were hostile to and demanding of the medical attendants and the patients were uncooperative throughout the whole treatment period. Rehabilitation of the two children was jeopardized. The situation was very difficult when they were first seen at the Prince of Wales Hospital. The burn surgeon at the Prince of Wales Hospital, as a third party, managed to act as a bridge between the referring hospital and the patients and their families. Several meetings were held and the best interests of the two patients was addressed. The compensation issue was also settled without formal legal prosecution.

Bizarre paediatric facial burns

Child abuse and neglect account for a significant number of paediatric burn injuries. It is of great importance because of the high mortality, high frequency of repeated abuse, as well as the physical, psychological and social sequelae that it causes. Burn abuse is often under-recognized and under-reported because it is difficult to define non-accidental injury. On the other hand, false accusation of burn abuse is extremely damaging to the family. Bizarre and unusual burn injuries can be caused by accident and should not automatically be assumed to be deliberate injury. Three boys of age 1-7 years with bizarre facial burns were admitted to the Burns Unit at the Prince of Wales Hospital between February 1995 and July 1999. One was burned by his baby-sitter with hot water steam and the other two were burned by their mothers with hot boiled eggs. The unusual causes of their burns raised the suspicion of child abuse and formal investigations were carried out by the Social Services Department. Detail assessment including a developmental history of the child and the psychosocial assessment of the family revealed that these three boys were burned because of poor medical advice and innocent cultural belief.

A prospective controlled clinical study of skin donor sites treated with a 1-4,2-acetamide-deoxy-B-d-glucan polymer: a preliminary report

The effect of Hyphecan (1-4,2-acetamide-deoxy-B-D-glucan) on skin donor site healing was compared with the standard skin donor site dressing Kaltostat (calcium sodium alginate) in 35 burn patients with 70 skin donor sites prospectively. The median time of wound healing for the Hyphecan group was 12 days with an average of 13.1+/-4.0 days (ranged from 9 to 28 days) while the Kaltostat group had a median healing time of 12 days (ranged from 8 to 28 days) with a mean of 13.0+/-4.1 days. The difference in healing time between these two groups was statistically insignificant with a P-value of 0.95. The infection rate was 2.9% for both Hyphecan and Kaltostat. These 35 patients had been followed up from 10 to 16 months and no difference in long-term donor site morbidity between Hyphecan and Kaltostat had been observed. This finding was encouraging because the cost of Hyphecan is less than 50% of Kaltostat and it may be worthwhile to explore the clinical application of Hyphecan in other area of burns treatment.

Skin care in burn patients: a team approach.

Skin care is an important but often neglected issue in burn management. Newly healed burn skin is fragile, itchy, dry, and susceptible to sunburn. Without proper skin care in burn patients, they may suffer from sleep and mood disturbances, depression, and poor compliance to treatment that can jeopardize the rehabilitation process. At the Prince of Wales Hospital, skin care has been managed since February 1996 by a team consisting of plastic surgeon, dermatologist, occupational therapist and nursing specialist. The purpose of this study was to evaluate the impact of a skin care program run by a Skin Care Team on the rehabilitation of burn patients in a tertiary burn centre. The role of different members of the team was also discussed.