Rural and remote paediatric burns in Queensland, characteristics and challenges

Dr Bronwyn Griffin1, Prof  Roy  Kimble1

1Centre For Children’s Burns And Trauma Research

Abstract:
Objectives

Children residing in areas outside major metropolitan centres may be at higher risk of injury incidence and adverse outcomes as they are routinely exposed to environmental hazards, travel long distances to receive medical care and are reported as more likely to receive adequate supervision The main objective of this study is to describe the relationship remoteness has with patterns of burn injury in Queensland children aged 0- 16 years.

Methods

A cross-sectional study was performed on consecutive patients treated by the Lady Cilento Children’s Hospital Burns Unit (LCCH-BU). Geographic remoteness was determined by postcode as per the Area Remoteness Index of Australia.  Descriptive analyses were conducted to examine differences between demographic and injury characteristics and if these varied between geographic remoteness groups.

Results

From 2013 to 2016,  2,540 burns families were interviewed. Overall, 91.6% were residents of the Metropolitan areas. Remoteness did not significantly differ between gender, age or TBSA%. However, several factors were associated with Non-metropolitan (NM) burns including, longer admissions (p<0.0001), deeper burns (p<0.0001), grafting (p<0.0001), flame burns (p<0.001), socioeconomic disadvantage (p<0.0001) as well as burns occurring in Aboriginal and Torres Strait Islander children (p<0.0001).

Conclusion

Our results confirm that children from NM areas treated at the LCCH-BU sustained burns with complex clinically needs, who were more likely to affected by socioeconomic or culturally challenges.  This information is vital for clinicians and social services to consider whilst treating the NM  burns families who are more likely to be undergoing external stressors that could impact care capacity.

Biography:
Dr Griffin is the Clinical Research Manager for the Centre for Children’s Burns and Trauma Research in Brisbane Queensland. She gets to work with a fabulously engaged and committed team of researchers and clinicians who inspire her every day.

 

Laboratory testing in burns: What do we order on admission?

Mrs Miranda Pye1

1Concord Burns Unit

Abstract:
This study involved a retrospective audit of laboratory investigations utilized at Concord Repatriation General Hospital’s Severe Burns Injury Unit over a two-month period, from January to February 2016. 62 patients were recruited from the unit’s admission book. The aim of this study was to determine which laboratory investigations are commonly ordered on admission, which tests were commonly abnormal and the cost of the testing conducted.

The audit identified 73 individual laboratory investigations were conducted as baseline results during this period. The most common pathology investigations panels include: electrolytes urea & creatinine, kidney function, full blood count, calcium magnesium & phosphate and liver function. The most common microbiology investigations include superficial wound cultures and MRSA screens. The audit identified several tests undertaken had higher rates of abnormal results. 15% had low sodium levels, 46% elevated white cell count and 27% low albumin. 69% of this sample had positive superficial wound cultures, of which only one was multi-resistant. Based on the data collected and the MBS figures the costs of the laboratory investigations conducted ranged between $25.35 – $169.40. The average cost for each patient’s initial laboratory tests was $85.07.

Overall the frequency of admission laboratory testing for patients within the burns specialty is minimal, with 32% audited not having any form of laboratory testing. This may be due to the minor nature of many of these injuries and the patient’s short length of stay.

Biography:
Miranda is a clinical nurse specialist. Who began working in her burns nursing career in 2003 as a student nurse, as a RN in 2005 and CNS in 2009. She has experience in all areas of the Burns Unit including Ward, Burns Operating Theatre, Burns Ambulatory Care and Telehealth. In addition to her 12 years’ clinical experience, she has completed a Bachelor’s degree in Nursing, the Graduate Diploma in Nursing Science – Burns Nursing and is currently undertaking her Masters in Nurse Practitioner. Miranda has also been a ANZBA member for 12 years and is currently a member of the ANZBA Nursing executive.

Endone patient information pamphlet

Mrs Miranda Pye1

1Concord Repatriation General Hospital, Burns Unit

Abstract:
Oxycodone is a commonly used opioid analgesic medication.  It has been identified as one of the most frequently prescribed, new medications for patients treated at Concord Repatriation General Hospital’s Severe Burns Injury Unit. Which is typically used for breakthrough and procedural pain relief.

Due to the need to provide education to patients prescribed this medication, a patient information pamphlet was developed to formalise and assist this process.

This poster aims to illustrate the side effects, indications for use, contraindications, administration guide and helpful tips.  It presents this in layman’s terms as the information provided is aimed at patient education within a burns setting.

Biography:
Miranda is a clinical nurse specialist. Who began working in her burns nursing career in 2003 as a student nurse, as a RN in 2005 and CNS in 2009. She has experience in all areas of the Burns Unit including Ward, Burns Operating Theatre, Burns Ambulatory Care and Telehealth. In addition to her 12 years’ clinical experience, she has completed a Bachelor’s degree in Nursing, the Graduate Diploma in Nursing Science – Burns Nursing and is currently undertaking her Masters in Nurse Practitioner. Miranda has also been a ANZBA member for 12 years and is currently a member of the ANZBA Nursing executive.

Severe burns due to a catastrophic failure of a modified driptorch: A case report

Dr Peter Meier1, Ms  Anna  Goodwin-Walters1,2

1State Burns Service of Western Australia , 2Fiona Stanley Plastic and Reconstructice Service

Abstract:
Introduction: Driptorchs are tools used in agriculture to intentionally ignite fires for burning off of wheat stubble. The driptorch comprises of a fuel reservoir canister connected to a spout containing a loop designed to prevent fuel igniting in the canister. A breather valve allows oxygen into the canister as it exits via the spout, and the wick at the end of the spout drips ignited fuel, usually a mix of petrol and diesel onto the wheat stubble (Figure 1). Homemade driptorches and adaptions to commercial driptorches are routinely undertaken and attached to farming vehicles.

Objectives: This is the first case report of a severe burn reported in the literature related to catastrophic failure of a homemade driptorch modified and attached to a vehicle.

Methods: A 57-year farmer was airlifted via helicopter with TBSA 10% burns to his face, right arm and flank after a modified driptorch ignited (Figure 2).  The modified driptorch included a fuel canister combined with a nine-liter LPG cylinder as a continuous ignition source, with a plastic spout and wick without non-return valves, attached to his vehicle tray. After the spout became blocked, the farmer was on the tray removing the blockage from the spout, fuel sprayed on him and tray of the utility igniting both the vehicle and the farmer (Figure 3, 4).

Conclusion: Driptorches are dangerous pieces of farming equipment and strict guidelines and standards should be mandatory to ensure their modification and safe practice is implemented in the agricultural and forestry industries.

Biography:
Service Registrar, State Burns Service WA

Positive pressure of negative pressure wound therapy

Dr Douglas Copson1,2, Prof Fiona Wood1, Mr Jeremy Rawlins1,2

1Fiona Stanley Hospital, 2Royal Perth Hospital

Abstract:
Background

Negative wound pressure therapy is being applied in an ever increasing range of clinical situations. The use of NWPT on closed incisions has gained popularity recently as well as the use of NWPT in burns patients to apply compression over split skin grafts while providing an effective method of exudate control.

Methods / Design

We undertook a study looking into the macroscopic positive pressure VAC dressings apply over closed uninjured skin. Pressures were tested on a healthy volunteer over the anterolateral thigh to record real world pressures. Pressures were also tested on a solid surface to record the relationship of set negative pressure to maximum macroscopic positive pressure applied to a closed wound.

Results

We found that when NWPT was applied over uninjured skin the positive pressure applied to the wound was constant across a wide range of negative suction settings. The surface pressure increased when NWPT was applied over wound beds with increased densities.

When tested NWPT on a solid surface to record maximum positive pressure NWPT could deliver over a closed incision there was a linear relationship ranging from 11mmHg positive pressure at a setting of -25mmHg to 40mmHg at a setting of -200mmHg.

Conclusion

This study provides further data in understanding the mechanism of negative wound pressure therapy. Understanding the pressure applied via NWPT can guide clinical application over pressure sensitive structures such as free flaps and also rigid structures such as periosteum/bone.

Key Words

Negative Wound Pressure Therapy

Biography:
Dr Douglas Copson is a Plastic and Reconstructive Surgery registrar training in Perth, Western Australia.

Prediction of mortality in severe burns patients

Dr Albert Kim1, Dr Pratik Rastogi1, Dr Edward Riordan1, Dr  Jeon Cha1, Dr Robert Gates1

1Severe Burns Unit, Royal North Shore Hospital

Abstract:
Background/Aim

Mortality predicting scores following burn injury can be valuable in guiding clinical decision-making and counselling families. The aim of this study is to identify burns mortality predictive scores and to demonstrate their usefulness on a retrospective cohort of burns patients that were admitted to the Severe Burns Unit at Royal North Shore Hospital.

Method

A systematic review identified the revised Baux, Abbreviated Burn Severity Index (ABSI) and the Belgian Outcome in Burn Injury (BOBI) scores as suitable burns mortality predictive indices. This retrospective study included all patients admitted to RNSH from 2006 to 2017 with ≥50% total body surface area (TBSA) burns. There were no additional exclusion criteria. The accuracy of each scoring system was assessed using receiver-operator characteristics curve analysis.

Results

During 2006-2017, 3002 patients were admitted to RNSH. 2% (n=56) had burns ≥50% TBSA burns. The mean age was 39yrs, mean TBSA burns was 71% and inhalation injury was present in 61% (n=34). The total mortality rate was 52%. In comparing burns survivors to mortality cases, significant differences were noted in mean age (35yrs vs. 44yrs, p=0.018), TBSA (63% vs. 78%, p<0.001) and Baux score (107 vs. 133, p<0.001). Survivors had a mean ABSI score of 11 (60-80% predicted mortality) and BOBI score of 5 (30% predicted mortality) vs. 13 (>90% predicted mortality) and 6 (50% predicted mortality) respectively in mortality cases (p<0.001, p=0.002).

Conclusion

The BOBI, ABSI and revised Baux sores may be used as clinical adjuncts to guide the management of severe burn patients.

Biography:
Albert Kim is a Surgical SRMO at Royal North Shore Hospital with a special interest in severe burn injury.

 

Guidelines for the treatment of Post-Burns Pruritus at The Children’s Hospital at Westmead

Miss Madeleine Jacques1, Dr Mahmoud El Bably1, Dr  Mitchell Nash1, Dr Alan Pham1

1The Children’s Hospital at Westmead

Abstract:
Pruritus in burns patients is common and distressing.

The mechanism of burn itch is complex and understood to have both central and peripheral pathways. Predictors of severe and/or prolonged pruritus include larger body surface area burns, burns of greater depth, grafting (with particular consideration of donor sites), hypertrophic scars and female gender.

Assessment and treatment of burn pruritus in the paediatric population is an area of great challenge. Unmanaged pruritus may ultimately lead to wound breakdown and/or delayed wound healing.

Early detection of the above predictors and early/aggressive (and in some cases pre-emptive) therapy is strongly advocated.

There is a paucity of research available relating to specific recommended therapeutic approaches to paediatric burn pruritus and large variances in practice across all paediatric burn units throughout the ANZBA network.

In 2015, Dr Mahmoud El Bably (Anaesthetic Fellow) with the support of Dr Mitchell Nash (Burns Fellow) and the multidisciplinary burns team at CHW commenced development of guidelines for the treatment of post-burn pruritus in the paediatric population. These guidelines offer a treatment ladder for the pharmacological pruritic management of burns < 15% TBSA without grafting, for inpatients > 15% TBSA or post grafting and for those outpatients undergoing procedural sedation in the Burns and Plastics Treatment Centre (BPTC).

These guidelines will form part of CHWs Burn Clinical Practice Guidelines and are envisaged to become a useful tool to assist in providing the highest standard of uniform and consistent care in the prevention and management of pruritus in our paediatric burn population.

Pseudoepitheliomatous hyperplasia and verrucous carcinoma – a clinical and diagnostic challenge!

Dr Kelly Thornbury1, Dr Pratik Rastogi1, Dr Robert Gates1

1Royal North Shore Hospital

Abstract:
Background

Patients with severe burns are subject to significant physiological, immunological and inflammatory insults in both the acute and chronic phases of their care. Within this milieu, chronic skin changes are inevitable and debilitating. Ulcers in burns patients typically present as flat and slowly progressing wound, typically without exophytic or papillomatosis changes. Verrucous carcinoma, a form of Marjolin’s ulcer, is rarely seen in burns patients. (Chun-Yuan et al, 2010.)

Case

We present the case of a 34 year-old male who sustained 75% TBSA burns after a house fire as a 2 year old. Over a decade, he developed a chronic ulcer over his left Achilles wound, characterized by pseudo-polypoid tissue islands and progressive fibrosis. No periods of rapid growth or significant morphological change were reported. Pre-operative field incisional biopsies revealed pseudo-epitheliomatous hyperplasia without dysplastic features. The patient underwent a wide local excision of the Achilles wound and soft tissue reconstruction with a latissimus dorsi free flap. Formal histopathology unexpectedly revealed a low-grade verrucous carcinoma. He subsequently underwent re-excision of his involved margins as a complete oncological resection.

Conclusion

Surgeons managing chronic burns patients must maintain a high index of suspicion in surveying patients with ulcerative skin changes. Differentiating between pseudo-epitheliomatous hyperplastic changes and verrucous carcinoma remains a diagnostic challenge.

Reference

Huang. C. Feng, C., Hsiao, Y., Chuang, S. & Yang, J., 2010, Burn scar carcinoma,

Journal of Dermatological Treatment, 21:350–356

Biography:
Accredited Plastic Surgery Registrar

Repeat acute burns presentations amongst patients within a single institution

Dr Henry Shepherd1, Dr Kelly Thornbury1, Dr Aruna Wijewardana1, Dr John Vandervord1, Dr Jeon Cha1

1Royal North Shore Hospital

Abstract:
Most individuals that present to a Burns Unit for management of an acute burn are doing so for the first time. This is in response to a single isolated event. Once treatment is completed they will likely never again present for management of an acute burn. This is, however, not always the case. A small percentage of patients re-present to burns units with new acute burns for a number of reasons. This study examines the incidence and aetiology of these burns. We performed a retrospective review of repeat burn presentations to the Royal North Shore Hospital Severe Burns Unit between January 2013 and January 2017. Of 3066 patients managed during this period, 32 (1%) re-presented on one or more occasion with acute burns. Ninety-two burns were treated amongst this group at a range of 2 to 16 burns per patient. The average total body surface area (TBSA) for these burns was 1.5%. Sixty-nine percent of burns amongst this group were accidental, with the remaining 31% resulting from self-harm. Thirty-eight percent of patients had a significant mental health diagnosis, 29% had concurrent drug and alcohol problems, and 13% had an underlying medical issue predisposing them to the burn. Repeat burns presentations are a rare occurrence. It is important for clinicians to identify the underlying cause of re-presentations to prevent or limit future burns related injuries in these individuals.

Biography:
Henry is an unaccredited burns and plastics registrar at Royal North Shore Hospital in Sydney

 

A case of pseudemonal keratitis in a 63% TBSA burn

Dr Henry Shepherd1, Dr Andrew Turner1, Dr Aruna Wijewardana1, Dr John Vandervord1, Dr Jeon Cha1

1Royal North Shore Hospital

Abstract:
Bacterial keratitis is a rare but serious medical condition that carries a significant risk of permanent vision reduction or loss. A variety of bacteria have been isolated from patients with keratitis and it is postulated that these derive from local environmental sources. Predisposing factors include extended use of contact lenses, ocular surgical procedures, ocular disease and ocular injury. To our knowledge there has been no reported instance of bacterial keratitis developing after burns to the face.

We report a case of a 26-year-old male who developed pseudemonal keratitis during an acute burn admission following a house fire in 2011. The patient sustained full thickness facial burns as part of an injury totalling 63% total body surface area. During the admission he developed pseudemonal septicaemia and was noted to have new onset bilateral corneal opacifications and purulent ocular discharge on day 8. A diagnosis of severe fulminant bacterial keratitis was made and pseudomonas aeruginosa was grown from corneal scrapings. His visual acuity slowly improved with antimicrobials however he later developed exposure keratopathy secondary to cicatricial retraction from the burn. This was initially managed with splints however 18 months later he required bilateral ectropion release and eyelid grafting. On review 6 years post-burn his visual acuity had improved to 6/9 bilaterally and he complained of only mild ongoing discomfort.

Although rare, this case demonstrates the potentially severe and multifaceted nature of ocular sequelae resulting from facial burns.

Biography:
Henry is an unaccredited burns and plastic surgery registrar at Royal North Shore Hospital in Sydney.

 

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About ANZBA

ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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