Si Jack Chong

The enhanced Total Body Wrap—The new frontier in dressing care for burns

The management of extensive burns with their associated high fluid exudate following burn excision and skin grafting has always posed a challenge in burn wound care. The ideal dressing should protect the wound from physical damage and micro-organisms; be comfortable and durable; allow high humidity at the wound; and be able to allow maximal activity for wound healing without retarding or inhibiting any stage of the process. The dressing technique described in this paper fulfils all the criteria above and at the same time provides an efficient channel to effectively clear the excessive exudate produced while keeping the wounds moist. Advantages conferred include accurate charting of wound exudate; reduced frequency of dressing changes; lower infection rates through prevention of strike-through; and securing and improving the viability of skin grafts. An enhancement to a technique previously described by us through the use of long thin strips of VAC sponges to transmit negative pressure, the enhanced Total Body Wrap aims to provide ideal conditions to promote healing in burns. Using negative pressure wound therapy (NPWT), this technique is simple and straightforward enough to be applied in majority of tertiary centres around the world.

Use of multiple VAC devices in the management of extensive burns: The total body wrap concept

0305-4179/

The trends of burns epidemiology in a tropical regional burns centre

36.00 # 2010 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2010.05.007 challenges in modern burn care [1–3]. The heavy fluid output overwhelm most conventional dressings resulting in contamination and increased infection rates [4]. We describe the total body wrap concept: a dressing method that employs multiple VAC (vacuum assisted closure) devices to maintain a clean moist wound environment to enhance graft take while facilitating accurate exudate charting and graft visualisation. Small sponges acting as wicks are placed in dependent areas instead of using large sponges covering the entire wound.

Biobrane for burns of the ear – A novel technique

INTRODUCTION Singapore General Hospital (SGH) is a regional burns centre in Southeast Asia and is the only dedicated burns facility providing specialized burns care in Singapore. METHODS A cohort study was performed for burns patients admitted to SGH from 2011 to 2013. We compared our data with earlier studies and observed the trends of burns epidemiology in Singapore. Results were analyzed using the SPSS programme. RESULTS 655 patients were admitted during this study period, a 35.9% increase from 2003 to 2005. Scalding by water and flame injury remain the top causes of burns and the mean extent of burn is 9.5%. TBSA correlates with the incidence of burn infection, bacteremia and mortality. Patients with ≥20% TBSA are at a higher risk of bacteremia, and ≥ 34% TBSA is a predictor of mortality. 4.9% (n=32) of our patients developed bacteremia. Bacteremia was associated with a surgical duration of ≥80min. Patients with bacteremia incurred longer hospitalization, and had higher mortality rates. Overall mortality rate of our burns patients has decreased from 4.5% to 2.7% (n=18). Key factors of mortality include inhalational injury, bacteremia and ≥20% TBSA. CONCLUSION This is a large epidemiology study of a tropical region burns centre. A total of 655 burns cases over a 3-year period were analyzed. We analysed the key factors associated with adverse outcomes including burns infection, bacteremia and mortality, factors associated with mortality, and discussed strategies on the optimization of burns care.

Biobrane™ for burns of the pubic region: minimizing dressing changes

[ espite these advantages, this form of therapy is less opular for burns in areas such as the face and ears, mainly ue to the difficulty in application to the contours of these reas. In a trial comparing the use of topical agents versus skin ubstitutes for the facial burns, wound care time, pain and ealing time were significantly less in the skin substitute roup [2]. Biobrane application to the face has also been escribed in two reports, both as a single sheet and as separate ieces [3,4]. To our knowledge, there have not been any reports hat document the application of Biobrane to the ear, a rominent and yet difficult region to dress. Our patient was a 38 year old gentleman who sustained ash burns to his face and bilateral ears, all of which were of artial thickness. After debridement, Biobrane was applied s a single sheet to the face, with two separate sheets for the ars. The Biobrane was applied to the contours of the anterior nd posterior surfaces of the auricle, using Vicryl Rapide 5-0 uture to immobilize the Biobrane and provide good contact etween the surfaces. The right ear is shown in Fig. 1. No urther dressings were required and the Biobrane was emoved easily one week after application, showing comlete healing (Fig. 2). Dressing for partial thickness burns of the ear commonly nvolves topical agents such as antibiotic ointment, as ressing of this region is challenging. However, this has to e applied frequently and increases the burden of care for the atient. On the other hand, Biobrane is a one time dressing hat requires little maintenance thereafter. If applied well, the Biobrane should contour well to the oncavities and convexities of the auricle, and the Vicryl

From skin allograft coverage to allograft–micrograft sandwich method: A retrospective review of severe burn patients who received conjunctive application of cultured epithelial autografts

BackgroundThe pubic region is often involved in accidental hot water or soup-spill burns. Most of these wounds are superficial partial thickness burns. Due to their proximity to the urinary system, as well as vaginal and anal openings, these burns are easily contaminated. Daily dressings are routinely prescribed as the sole treatment. The cumbersome dressing process is uncomfortable and embarrassing for patients. Biobrane™ is a bilayered biosynthetic dressing. Its coverage of superficial partial thickness burns promotes wound healing and allows one-time application.Case presentationsWe report two patients who suffered superficial dermal burns over their pubic region. One patient had 23% total body surface area (TBSA) burns over her lower abdomen, both thighs and pubic region. The second patient had 10% TBSA burns that involved her perineum and the medial sides of both thighs and buttocks. Both were managed with the standard resuscitation protocol in the initial phase. Their burn injuries were managed by shaving, Foley catheterization and Biobrane™ coverage. Their wounds healed uneventfully without complications. Full epithelization was achieved by post-operative day seven. Both patients consented to medical photography and academic publication.ConclusionShaving and catheterization improved the hygiene of the burns of the pubic area. The Biobrane™ method circumvents the need of regular dressing changes, eliminating the pain due to dressing changes and preserving patient dignity.

Early definitive treatment of partial-thickness alkali burns with tangential excision and biobrane

A 12-year retrospective review of severe burn patients who received cultured epithelial autografts (CEA) at the Singapore General Hospital Burns Centre from January 2005 to December 2016 was carried out. During this period, two different surgical modalities were employed to manage these burn injuries. In the earlier period, following early excision of the burn wounds, exposed surfaces were covered with a combination of split thickness skin autografts (STSG) and allografts. Surfaces covered with skin allografts were subsequently debrided of the allo-epidermis in about 3 weeks later, exposing the allodermis with granulating tissues for grafting of CEA; a technique known as the Cuonos method. In the later period, allograft-autologous micrograft sandwich technique was used to graft on the early excised burns with subsequent CEA grafting. The former and latter groups represented by STSG/C (n=10) and M/CEA (n=14) respectively, were compared in terms of clinical profiles, outcomes, allograft/CEA usage and total graft cost. No significant differences were found based on mean age and presence of inhalation burns between the two treatment methods However, percentage total body surface area (TBSA) and Revised Baux Score were significantly higher (p<0.05) in the M/CEA group compared to the STSG/C group. Differences in clinical outcomes of mortality and length of hospital stay between the 2 groups were statistically insignificant. The average area amount of skin allografts used per patient in the M/CEA group was significantly lower compared to the STSG/C method group which contributed to lower total average cost of grafts used per % TBSA in the M/CEA method group. This might be attributed to the presence of micrografts which seemed to improve stabilization of the wound bed resulting in less operating procedures and improving CEA take. To conclude, the M/CEA method introduced was able to treat more severe burn patients at lower graft costs without compromising critical clinical outcomes significantly.

Electric scooter burns and the danger of personal mobility device battery: Letters to the Editor

Copyright 2018 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copious irrigation, early tangential excision, and dressing are standard treatments for alkali burns [1]. Biobrane is a biosynthetic dressing widely used for partial-thickness burns. However, its use to treat alkali burns has rarely been discussed in the literature. A 34-year-old male suffered a partial-thickness alkali burn caused by accidental paint solvent spillage (Taxite 4000, pH 10) over his face, neck, chest, and hand (11% of total body surface area). Immediate hourly copious irrigation was commenced before a same-day operative scrubdown. After intraoperative irrigation and scrubbing with neutralizing chlorhexidine gluconate 4% liquid soap (pH 5.0–6.5), only the upper limbs were still alkaline (Fig. 1). Hence, we proceeded with ultra-thin tangential excision and debridement over the right upper limb until a litmus test indicated a neutral pH. Biobrane was applied onto the dry clot-free wound bed with sterile Hypafix (Fig. 2). The Biobrane adhered well, was sequentially trimmed, and the wound was exposed by postoperative day 12. The right arm healed by 1 month postoperatively (Fig. 3). Minimal scars were present, only on the medial portion of the right hand, at a 1-year follow-up (Fig. 4). After continuous irrigation, debridement via the

Establishing a treatment protocol for concomitant major burn and trauma patients: a tropical Asian hospital’s experience

The E-scooter has become popular in Singapore since late 2016 as personal mobility device for close distance travel partly due to law enforcement on electronic bicycles. Its initial concern regarded speeding and its involvement in road traffic accidents, which was addressed by imposing new rules placing restrictions on E-scooter weight and speed limits. However, a recent event has sparked new concern, namely, its ability to cause an explosion and severe burn injuries to its user. In November 2017, an E-scooter battery exploded at a residential flat in Yishun, Singapore, which led to a fire outbreak. The E-scooter was found to be burned at scene, with its battery melted (Fig. 1). Four victims was brought to Singapore General Hospital; two suffered from inhalation injury; one had a superficial burn to the hand; and one of the victims had suffered burns to 30% of his body, requiring surgery and admission to intensive care unit. This incident was the 33rd case of an E-scooter catching on fire in 2017. Due to a surge in market demand and products that are easily available online, certification and safety checks on the product appear to be lacking regarding this matter. Consumer awareness on safety measures when taking care of the lithium ion battery plays a crucial role in deterring such a tragedy. In this particular case, the E-scooter was purchased off an E-commerce website as a secondhand product. Hence, the consumer was not given a safety guide and specificities of the merchandise. The E-scooter was identified as using a Ternary Lithium ion battery with the capacity of 36 V, 10.4 Ah and contained components that could react and generate heat or flame. The ternary lithium ion battery is known for its higher energy density but also its poorer security, with a high temperature difference, hence making it easier to cause thermal runaway.

Comparison of four measures in reducing length of stay in burns: An Asian centre’s evolved multimodal burns protocol

Dear Editor, Burns and trauma represent two of the most severe injuries that both developing and developed countries face today. Concomitant burn and traumatic injuries are significant in terms of disease burden and cost of treatment due to associated high morbidity and mortality. Existing literature for burn and traumatic injuries encompass injuries derived from terrorism, warfare, natural disasters [1], and accidents. The most significant to date is the large-scale study by Kalson et al. on burn and traumatic injuries in England and Wales [2]. However, literature and outcomes regarding the multidisciplinary management and approach to concomitant burns and trauma in a developed Asian center are limited. The Singapore General Hospital (SGH) Burns Centre is the only adult burn center in Singapore and is the regional referral center in Southeast Asia. Our center receives 93% of all burn patients in Singapore including mass casualties from the region [3]. We conducted a retrospective case-control “trauma/ burns” study of 11 patients with concomitant major burn and traumatic injuries at SGH from 1998 to 2012 obtained from the SGH Burns Registry. Inclusion criteria were trauma with multiple injuries requiring activation of the trauma team (e.g., intracranial injuries, long bone fractures, abdominal injuries, inhalational injuries) and major burns of more than 15% total body surface area (TBSA). Exclusion criteria were patients who were dead on arrival or repatriation cases. We compared this group to a control group of 11 major burn (>15% TBSA) patients without traumatic injuries admitted during the same time period. Controls were randomly matched for TBSA and age. Both groups had similar demographics and burn characteristics for comparison. The median age is 37 and 39 years in the trauma/burns group and the control group, respectively. Majority of the patients are males (90.9% (n = 10) in trauma/burns, 81.8% (n = 9) in control). The median TBSA is 32% for both groups (16–90% and 15–88% for the trauma/burns group and control group, respectively) and of deep dermal depth. Occupational burns (e.g., electric and flash explosions, generator and gas cylinder explosions) is the majority in both study and control groups (73% (n = 8) of patients from both groups). This highlights the importance of workplace safety such as protective equipment, regular preventive maintenance and job-specific hazard analysis implementation. In our study, the severity and high mortality (36.4%) of patients with concomitant burn and traumatic injuries highlights the focus on managing these critically ill patients well. In contrast, the mortality for control group is 9.1% (n = 1) and the international average mortality rate is lower for burn injuries alone (3.1–18%) [4, 5]. Burn intensive care unit (BICU) admission rate was 90.9% (n = 10) in trauma/burn patients (due to their severe injuries) and 45.5% (n = 5) in the control burns only group. Patients in the trauma/burns group mostly belonged to Clavien Dindo Classification terminal grades of 4A (n = 7) and 5 (n = 4) compared to patients in the control group who were mainly grades of 3B (n = 6) and 3Bd (n = 4). * Correspondence: yeeonn.kok@mohh.com.sg Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore 169865, Singapore Full list of author information is available at the end of the article