Search

Ringer’s lactate has been the most widely used fluid for burn resuscitation for decades. Plasmalyte® (PL), a newer balanced crystalloid, is gaining popularity for use in the critically ill, including patients with burns. This popularity is partly due to the fact that PL theoretically offers a favorable metabolic profile, but may also be attributed to its relatively lower cost. Patients who are critically ill with large burns receive enormous volumes of fluids, especially during the resuscitation period. The choice of balanced crystalloid solution used is likely to have an impact on the metabolic status of patients and their overall outcomes. The choice of fluid for burn resuscitation has been one of the most researched topics in burn care and various types of fluids have been superseded based on research findings. This narrative review examines the evidence guiding fluid management in burns and explores the data supporting the use of balanced crystalloid solutions, in particular PL for burn resuscitation. Our literature search revealed only one study that focused on a direct comparison between PL and standard Ringer’s Lactate for burn resuscitation. Based on the limited literature on the use of PL in burns, it is difficult to draw meaningful conclusions. Further research, into the suitability of PL for use in burns, is needed before formulary changes are instituted widely.

Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation.In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk.A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed.In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

Severe burn injury is a serious systemic insult that can lead to life-threatening secondary infections. Immunosuppression, inhalation injury, and prolonged length of hospital stay are factors that predispose patients to severe respiratory tract infections. Furthermore, evidence shows that burns can put one at risk of infection long after the original injury. Currently in the United Kingdom, the annual National Flu Immunisation programme outlines guidance for groups who are deemed high risk and, therefore, eligible for the influenza vaccine. At present, no guidance exists for the administration of the influenza vaccine in burn-injured patients, despite knowledge of immunosuppression. The aim of this literature review is to examine the evidence for associations between burn injury and influenza and, where available, evaluate efficacy of influenza vaccines in this cohort. In addition, literature was searched for the effectiveness of the influenza vaccine in patients 65 years and above and in patients admitted to the intensive care unit (ICU), two domains common to patients with severe burns. Three papers were found to suggest increased susceptibility to influenza following burn injury; however, no papers studying the effectiveness of the influenza vaccine in this group were found. Several studies demonstrated improved outcomes in patients over 65 years and patients admitted to ICU. Following the evaluation of the evidence, this review advocates for the consideration of hospitalized burn patients for the influenza vaccine. We suggest the avoidance of vaccine administration in the acute burn phase. Further prospective clinical trials would be required to validate these findings.

Introduction There has been considerable concern in the UK with what seems to have been an increase in so-called ‘Acid Attacks’. The key data sources (Police data, Hospital admissions and Burns unit data) have limitations in capturing the acid attacks comprehensively. Incidents not reported to the police are missed in the Police data. The more serious injuries are included in the hospital admissions data, with no information on people with less severe injuries, not accessing health care. Burns unit data reveals detailed information on the burns treatment but represents only a small percent of all the acid attacks. Our aim was to explore the role of media reports as an additional data source. Methods Data was obtained from the public domain using generic online search engines along with a formal medical literature review. Search parameters included any news articles on ‘Acid Attacks’ printed between 01/01/2016 and 31/12/2017 in England and Articles in National Press only. We compared the data from media reports to the only other data sources available on these crimes which were (a) Crime statistics from police (b) the proportion treated in hospital (c) the subgroup treated in the burns service in the highest incidence location in the UK. Results Two hundred and Thirty media articles in total were found in the preliminary search. Following the application of the exclusion criteria, sixty attacks were analysed. The demographic data, the geographic data were obtained from the articles and the results were analysed using Microsoft Excel. There were a total of 118 survivors with an average age of 29.5 years and a male to female ratio of 5.1:1. There were no reported deaths. In the assailants group, the average age was 21.6 years with a male to female ratio of 15.7:1. All the data sources revealed higher male survivor predominance. The average age of the survivors was similar in the media reports, police data and the Burns centre data and was higher in the hospital data. Information on assailants and motives, available only on media reports and police data, corroborated well with each other. Media reports gave further information on the circumstances of the incident, the location and the number of survivors per assault, which was not available on any other data source. Though there was a rise in chemical assaults reported in media reports and MPS data in 2017 compared to the previous year, there was no rise in chemical assault related hospital admissions. Conclusion The majority of the survivors were males, which is consistent between all UK data sources. Media reports revealed that the South east of England had the majority of chemical assaults in England. Data from this source provides a further piece in the jigsaw especially in relation to the circumstances, the geographic location of the chemical assault and number of survivors per incident. We acknowledge the limitations of media reporting. In the absence of a formal database for such injuries and incomplete data from various sources, we have to consider all possible data sources to provide new information. We have discussed the utility, pros & cons of media reports as one of the additional sources of information to better understand these injuries.

Hand burns are common and often complex injuries, requiring referral to specialist centers. The patient’s thumbprint is a rapid means of accurately assessing hand burn surface area. This study aimed to establish categories and evaluate sites of hand burn surface area in order to facilitate comparison of hand burns. Sixteen burns involving the hand and wrist among 14 patients referred to a burns center were retrospectively categorized by burn mechanism, burn thickness, and hand burn surface area. The burn surface area in the clinical record was compared with that calculated by the thumbprint method and the rule of thumb diagram. Burn surface area in the clinical record was either “1%” or “

Introduction Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. Results An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. Discussion The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. Conclusions More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

Introduction: Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol. Methods: We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated. Results: The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray. Conclusion: Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area. Lay Summary A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Summary Background Burns patients are at high risk of nosocomial infection, and Pseudomonas aeruginosa is one of the most common causes of wound and systemic infections resulting in significant morbidity and mortality in burns patients. Aim To describe an outbreak of multidrug-resistant P. aeruginosa (MDR-Pa) at a specialist burns service and highlight the challenges in identifying the reservoir of infection despite extensive epidemiological, microbiological, and environmental investigations. Methods Multi-disciplinary outbreak control investigation. Findings Following an inter-hospital transfer of a burns patient from another country, an admission screen revealed that the patient was colonized with MDR-Pa. Subsequently nine more patients contracted MDR-Pa in the period from November 2015 to September 2017. Given the relatively long gap between confirmation of the index and subsequent cases, it was not possible to identify with certainty the reservoirs and mechanisms of spread of infection, although contamination of the burns service environment and equipment are likely to be contributory factors. Conclusion Preventing infection transmission in specialist burns services is highly challenging, and it may not always be possible to identify and eradicate the reservoirs of infection for P. aeruginosa outbreaks. Our study supports the literature, providing additional evidence that inanimate, common contact surfaces play an important role in nosocomial transmission of P. aeruginosa. These surfaces should either be decontaminated efficiently between patient contacts or be single patient use. Enhanced vigilance is crucial, and, with strict adherence to infection prevention and control procedures, it is possible to reduce the risk of acquisition and spread of infection in patients.

Photodynamic therapy (PDT) involves the use of a photosensitiser, a light source and the presence of oxygen to create reactive oxygen species (ROS) intercellularly. The accumulation of free radicals directs cell apoptosis and modulates cellular protein expression and signalling. PDT has a range of applications including treatment of cancers, in particular of the skin. It is recommended by the British Association of Dermatologist for actinic keratoses, Bowen’s disease and superficial basal cell carcinoma [1]. Off label, it is used in inflammatory and infective conditions such as acne, psoriasis and viral warts [1, 2]. Recent research has found PDT to be effective in scar management including hypertrophic, keloid, striae and burns scars in animal, ex vivo and case studies.

This chapter investigates the use of Pulsed Dye Laser (PDL) as a therapeutic tool for hypertrophic burns scarring. The progression of hypertrophic scars from burn wounds is first described. The chapter then reviews the evidence for treatment of hypertrophic scars with PDL. The efficacy of PDL for both prevention and treatment is summarised for all hypertrophic scarring with particular emphasis on early intervention. The chapter concludes with recommendations for treatment methodology using 595 nm PDL and gives photos of a case example.

No treatment or intervention is without risk. The only way to completely avoid any complication is never to treat. In certain circumstances, not treating can be the best option for a range of reasons beyond the scope of this chapter.

This chapter details best practice in relation to safely conducting laser treatments, including laser scar management, through appropriate use of test patching. This can limit complications such as hyper-pigmentation, hypo-pigmentation and scarring. It is also good practice in relation to limiting potential medico-legal claims.

Intense pulsed light (IPL) is a non-coherent filtered flash lamp, emitting a broadband spectrum (515–1200 nm) of visible polychromatic-pulsed light of a high intensity [1]. As such, it is not a laser technology per se using a filter to narrow the spectrum of light rather than emitting a single wavelength of light as lasers do. Its use was first conceived as therapeutic treatment of vascular lesions in 1992 [2].

The use of corrosive substances has unfortunately increased in some parts of the world including the UK; In 2006–2007, there were 44 admissions to hospital as a result of these assaults and there has been a year-on-year rise to 110 in 2010–2011. Recent evidence has shown that these attacks tend to occur in certain pockets of the country, mainly in the South East, that the victims tend to be Caucasian men and the perpetrators tend also to be Caucasian men. This is a previously undocumented demographic pattern.

This chapter focuses on the basic pathophysiological mechanisms associated with scarring. Anatomy and physiology of the skin, as well as our current understanding of how scar tissue forms, and how the process of scarring can be modulated are described.

Heterotopic hair growth is characterised by excessive hair growth in an abnormal anatomical location. The most common causes in the general population include an overproduction or increased sensitivity to circulating androgens, although most patterns of hair growth vary depending on sex and ethnicity [1]. In patients who have required reconstructive surgery, this can lead to hair-bearing donor tissue being present in non-hear-bearing areas, or an excess. Examples include: ear reconstruction with hair-bearing scalp skin leading to hairy ears; skin grafts such as full-thickness skin from the groin causing course or even pubic hair on the reconstructed areas including the face; and internal reconstructions such as tongue, floor of mouth, nose, lumen of the penis or neovagina after reconstruction growing hair.

The aim of this chapter is to provide an overview of consent as relevant to laser therapy. This is especially relevant because lasers and laser treatment can be complex and difficult to explain, may require multiple sessions and have a distinct risk of complications that can be mitigated through good communication, safe practice and appropriate documentation.

Laser scar management is a complex area that relies on the use of a number of different laser modalities to achieve a variety of modulatory effects on scar tissue. The challenges involved include the availability (and cost) of a range of lasers, clinical experience—especially with complex conditions such as burns, and hence patients tend to gravitate to regional and supra-regional referral centres where sufficient numbers of patients are treated. This chapter provides clinical examples of laser interventions for patients with a range of scars including complex burns scars, keloid scars, and how lasers can be used to improve scarring.

ObjectivesIdentifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients.DesignContent for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey.SettingWithin outpatient secondary care.ParticipantsTwelve adult burns patients and MDT members from two regional burns centres.ResultsA total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items).ConclusionsThe Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter.

The initial management of patients with an acute burn injury is often undertaken by individuals with relatively little experience in this area. To optimize outcomes and minimize the risk of long-term sequelae, clinicians should understand the key steps in initial management and safe transfer of these patients to a specialist burns unit. These include safely extricating patients and providing prompt first aid at scene; rapidly and accurately assessing them at the nearest emergency department or trauma centre; appropriately managing their airway and oxygenation; obtaining intravenous access and initiating fluid resuscitation; assessing burn extent and depth and considering the potential need for escharotomies; providing analgesia and appropriate tetanus prophylaxis; and covering and warming the patient while temporarily dressing their burns. Once these measures are taken, any patient with a burn injury may be discussed with a specialist burns unit for advice. If deemed necessary and accepted, they should be promptly transferred to a burns unit with an appropriate escort. Prior to transfer, a systematic re-assessment should be undertaken, and any required treatments should be continued during the transfer. Copies of all referral information and the results of initial assessments and investigations should be sent with the patient to ensure a robust handover process.

Assessment of total body surface area of a burn injured patient is a crucial step in managing burn injury. The chapter describes a number of techniques from using the size of the patient’s palm as an estimate of 1% to the gold standard Lund and Browder Chart. Key caveats are explained, copies of the charts included as well as the use of the CE certified app Mersey Burns.

The burns multidisciplinary team includes surgeons, specialist nurses, anaesthetic and critical care specialists, operating theatre staff, physiotherapists, occupational therapist, play specialists, clinical psychologists and dieticians, with input from other specialties (eg. microbiology). Burns units receive referrals from primary and secondary care, usually by telephone. Referral proformas help to document these calls and any information provided about patients, their burns and associated injuries, the treatments provided and their planned transfer. The clinician accepting the patient for transfer must ensure that there is an available ward or ICU bed, as required, prior to arranging transfer. Care should be taken to minimize the risk of a patient deteriorating during transfer. Fluid resuscitation and patient warming should continue during a prompt transfer by an ambulance team with the appropriate equipment and expertise, along with a medical escort if required. Upon arrival, the patient should be formally and systematically assessed (including an ATLS primary and secondary survey and anaesthetic assessment if indicated) and any remaining investigations undertaken. The burn wounds should be cleaned, photographed, swabbed and dressed, and any resuscitation fluids recalculated and prescribed. Appropriate medications and adjuncts should be prescribed including tetanus, deep vein thrombosis and stress ulceration prophylaxis, analgesia, usual medications, and nutritional supplements along with enteral or parenteral feeds. An admission proforma helps junior medical staff to ensure that all required information is collected and all components of the standard management plan are instituted.

Exfoliating skin disorders or exfoliative and necrotizing disease of the skin form an important part for all those managing acute dermatological and plastic surgery emergencies; including the burns surgeon. It is imperative that such conditions are evaluated in a burns text as these patients should be managed on a burns unit with allied professional input. This chapter focuses on the classification, aetiology, and management of such disorders. Management includes initial assessment and suggested surgical approach. In addition scoring and prognostic indicators are referenced to allow the reader application of knowledge in clinical practice.

This chapter provides an overview of laser as applied to burns and scar management.

Frostbite is the damage sustained by tissues when exposed to temperatures below their freezing point (

This chapter explores the topic of non-accidental injury burns in children. It is important to consider the possibility of non-accidental injury and recognize injury patterns. The chapter gives a concise overview of the patient and parent characteristics, assessment of such patients and differential diagnoses to consider in the process of managing children in these situations. Patterns of injury in non-accidental burns are described.

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Follow the path of the unsafe, independent thinker. Expose your ideas to the danger of controversy. Speak your mind and fear less the label of ‘crackpot’ than the stigma of conformity.