Burn Injury Assessment through Tattoos: A Systematic Review

Dr Danika Jurat1, Dr Douglas Copson1

1Fiona Stanley Hospital, Murdoch, Australia

Abstract:

Background: tattoos are a form of body decoration increasing in popularity world-wide¹. By changing the colour of the skin with injection of pigment, assessment of burn injuries are made more challenging for the medical practitioner. A 46 year old male was admitted to the State Burns Unit of Western Australia secondary to an acetone explosion whilst fixing his boat. He received burns to his neck, chest and bilateral upper limbs. This gentleman was heavily, intricately tattooed to bilateral upper limbs with coloured and black pigments. His tattoos made the assessment of the depth of his burns difficult for the initial doctors assessing the patient and for ongoing reviews. This is on a background of 21 similar patients being admitted to the Western Australia State Burns Unit between 2012 and current.

Objectives: to perform a systematic, peer review of the literature on assessment of burn injuries through tattoos.

Data sources: A systematic literature search was performed across electronic databases including PubMed, EMBASE, MEDLINE and Cochrane to identify studies. Key words used were “burn”, “burn injury”, “tattoo”, “assessment” and “depth”.

Study appraisal: Two case reports were identified, one, a reflection on the clinical, diagnostic challenge of burn depth assessment overlying tattoos², the other assessing the depth of burn injury over tattoos utilising laser speckle contrast analysis (LASCA) imaging³.

Results:

  1. The case report on the diagnostic challenge of burn depth assessment overlying tattoos discussed issues with identifying colour and capillary refill, examination findings that assist in defining depth of the injury².
  2. The case report on LASCA imaging in burns overlying tattoos assessed the effect of varying shades of pigmentation, from non-tattooed skin to multi-coloured, on the relative perfusion analysis³. Tattoo pigments were shown to alter the results of perfusion patterns. Determination of depth was limited by variety of pigment shades³.

Conclusions: Extremely limited evidence available for assessment of burn injuries overlying tattoos. This review highlights the need for further research into the area.


Biography:

Danika Jurat is a resident medical officer working in the State Burns Unit of Western Australia with a keen interest in Plastic Surgery, particularly Burns

Experiences of engaging in Burn Rehabilitation via Telehealth in a rural setting

Ms Annette Lakeland1, Mr  David Rappoport1

1Tasmanian Health Service – North West Region, Burnie, Australia

Abstract:

Introduction: The use of teleconferencing to deliver healthcare is becoming increasingly common (Wilson & Maeder 2015), however there is limited research on the use of telehealth for burn scar management. The Tasmanian Burns Unit provides a telehealth scar management clinic to patients at a rural hospital in North West Tasmania, which minimizes travel for patients whilst still providing access to specialist care.

Aim: This study aims to identify the benefits and any challenges of using telehealth for burn scar management from a patient/carer and staff perspective in a rural setting.

Method: This mixed method study will survey patients and/or their carers who have attended the telehealth scar management clinic as well as local therapists involved in burn care utilising written questionnaires. An audit has also been completed on attendance rates at the telehealth clinic.

Results: Findings to be presented will include some of the common challenges such as technical difficulties and attendance rates, as well as benefits such as reduced travel time and cost for patients and their families.

Conclusion: The findings will help to guide future practice on the use of telehealth in subacute burn care.

References:

Wilson, LS & Maeder, AJ 2015, ‘Recent Directions in Telemedicine: Review of Trends in Research and Practice’, Healthcare Informatics Research, vol. 21, no. 4, pp. 213-222.


Biography:

Annette is a Senior Occupational Therapist working at The Tasmanian Health Service – North West Region with a passion for burn care and hand therapy.

Oven Door Burns in Queensland Children

Dr Alicia Miers1,2,3, Dr Bronwyn Griffin1,2,4, Professor Roy Kimble1,2,3,4

1Queensland Children’s Hospital, South Brisbane, Australia, 2University of Queensland, St Lucia, Australia, 3Centre for Children’s Burns and Trauma Research, South Brisbane, 4101, 4Queensland University of Technology, Brisbane, Australia

Abstract:

The aim of this study is to document and describe the effects of oven door burns in children. This project hopes to contribute to further evaluation of strategies to reduce the frequency and severity of oven door burns.

Retrospective burns registry and departmental database review of all children with oven door burns treated at The Stuart Pegg Children’s Burns Centre between July 1998 and October 2002 were compared with children treated at the Pegg Leditschke Children’s Burns Centre from the time of its opening in November 2014 to October 2018.

Results revealed that in the 1999-2002 group, thirty-four children, median age ten months, sustained partial thickness burns to the hands. One child required skin grafting and eleven (32%) required scar management. In the 2014-2018 group, seventy-nine children, median age eleven months, sustained superficial or partial thickness burns, with seventy-two cases (90%) involving the hands. Two children required grafting, and six patients required inpatient management. The median time to re-epithelialisation was 10 days for those patients that did not require grafting and 9 patients required scar management (11%).

Oven doors remain a hazard to the hands of young children, especially between the ages of seven and fifteen months. There has been no significant change to the nature or impact of oven door burns between these two groups of data spanning almost twenty years. Action is required to review the safety standards of household oven doors, as the current standards are not effective in protecting children from contact injuries.


Biography:

Dr Alicia Miers is a Registrar with the Paediatric Surgery, Urology, Burns and Trauma Unit at Queensland Children’s Hospital.

MolecuLighting up! BTM and the MolecuLight in the management of ataxia telangiectasia. A Case Report

Dr Alicia Miers1,2,3, Ms Kristen Storey1,2,3, Professor Roy Kimble1,2,3,4

1Queensland Children’s Hospital, South Brisbane, Australia, 2University of Queensland, St Lucia, Australia, 3Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Brisbane, Australia, 4Queensland University of Technology, Brisbane, Australia

Abstract:

Ataxia telangiectasia is a neurocutaneous syndrome characterised by faulty DNA damage repair. Cutaneous granulomas are a common presenting feature and require long term wound management in parallel with systemic immunotherapy (Privette st al. 2014).

This is a case report of the recent use of the MolecuLight and Biodegradable Temporising Matrix (BTM) in the management of lower limb ulcerating granulomatous skin changes complicated by pseudomonas infection in a 15 year old with ataxia telangiectasia.

Management of this patient’s granulomatous lesions over the last 12 months has included; twice weekly dressings, steroid injections, acetic acid washes, gentamicin washes, and most recently targeted cleaning and debridement with the help of the MolecuLight followed by operative debridement and application of BTM.

The MolecuLight is a point of care technology that uses bacterial fluorescence imaging to help nursing and medical team members identify bacterial contamination that facilitated targeted intervention including wound swabs and debridement (DaCosta et al. 2015). Novosorb™ Biodegradable Temporising Matrix (BTM) is a fully synthetic dermal scaffold for tissue repair, and contributes to stable, durable and flexible wound closure (Cheshire et al. 2016).

Together, these technologies have transformed the wound care management for this patient, including the reduced requirement for analgesia, sedation or anaesthetic for acetic acid washes. The wound care for this patient is ongoing and we hope to share our local experience of the management of this rare paediatric condition.

Reference List

Privette, ED, Ram, G, Treat, JR, Yan, AC & Heimall, JR 2014, ‘Healing of Granulomatous Skin Changes in Ataxia‐Telangiectasia After Treatment with Intravenous Immunoglobulin and Topical Mometasone 0.1% Ointment’, Pediatric Dermatology, vol. 31, no. 6, pp. 703-7.

DaCosta, RS, Kulbatski, I, Lindvere-Teene, L, Starr, D, Blackmore, K, Silver, JI, Opoku, J, Wu, YC, Medeiros, PJ, Xu, W, Xu, L, Wilson, BC, Rosen, C & Linden, R 2015, ‘Point-of-Care Autofluorescence Imaging for Real-Time Sampling and Treatment Guidance of Bioburden in Chronic Wounds: First-in-Human Results’, PLoS ONE, vol. 10, no. 3.

Cheshire, PA, Herson, MR, Cleland, H & Akbarzadeh, S 2016, Artificial dermal templates: A comparative study of NovoSorb™ Biodegradable Temporising Matrix (BTM) and Integra ® Dermal Regeneration Template (DRT), 03054179.


Biography:

Dr Alicia Miers is a Registrar with the Paediatric Surgery, Urology, Burns and Trauma Unit at Queensland Children’s Hospital.

Heparin induced thrombocytopenia management in burns: a case series and literature review

Dr Charles Meares1, Dr Derek  Liang1, Dr Aruna Wijewardena1, Prof John Vandervord1

1Royal North Shore Hospital, St Leonards Hospital, Australia

Abstract:

Introduction: Heparin induced thrombocytopenia (HIT) is a severe complication of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) therapy. An autoimmune disorder mediated by heparin-dependent IgG antibodies, it has the potential for widespread arterial or venous thrombotic complications. The aim of this study was to review cases of HITs in a severe burns centre highlighting outcomes and HITs management in the setting of burns.

Case Series: This is a case series of two patients who were managed for HITs whilst admitted with severe burns at Royal North Shore Hospital. A 34 year old male presented with 43% total burn surface area following a gas bottle explosion at home. His stay was complicated by HITs on day 16 post heparin infusion for deep vein thrombosis management. The second patient is a 54 year old male who presented with 45% total burn surface area post welding explosion. HITs was diagnosed day 8 during his admission whilst on UFH for deep vein thrombosis prophylaxis. The patients were managed acutely with different medical therapies for anticoagulation highlighting emerging therapies for HITs treatment in the intensive care setting with no bleeding complications during their admissions.

Conclusion: HITs is difficult to diagnose and a potentially devastating complication of UHF and LMWH therapy. The management of HITs also exposes burns patients to further haematological complications. The acute management of HITs is varied and the burns team must be aware of the options and implications for burns treatment.


Biography:

Charles Meares is an unaccredited trainee at Royal North Shore Hospital, Sydney.

A case of massive bowel infarction in a severe burn patient: a case report and literature review

Dr Charles Meares1, Dr Derek Liang1, Dr Aruna  Wejiwardena1, Prof John Vandervord1, Dr Robert Gates1

1Royal North Shore Hospital, St Leonards, Australia

Abstract:

Gastrointestinal complications in the setting of burns can be severe with a mortality rate of 45% [1]. Bowel ischaemia can develop at any time during the admission [1]. Severe burns patients are at increased risk of bowel infarction due to cardiovascular effects secondary to decreased intravascular volume and massive fluid shifts. Even with appropriate fluid resuscitation in the critical care setting, bowel oedema and intraabdominal hypertension can reduce bowel venous outflow, resulting in bowel ischaemia [2]. Surgical management of bowel infarction is complicated in the setting of burns with regards to diagnosis, abdominal closure and stoma care post-operatively [1].

We report a case of a 45-year old male who developed transverse and left colon infarction with an associated large perforation of the transverse colon during an acute burn admission following a gas explosion. The patient sustained full thickness abdominal burns as part of his 78% total burn surface area. Managed in the intensive care setting whilst intubated and on vasopressor support, his acute abdomen was detected on repeat CT imaging for suspected intestinal ileus on day 12. The patient underwent urgent laparotomy for total colectomy and ileostomy through his abdominal burn. The laparotomy incision was closed with staples and the stoma secured with 4-0 PDS. Judicious post-operative wound management and stoma care was integral to achieve a functioning stoma and wound healing.

This case highlights the danger of bowel infarction in the severe burns patient and the complex issues of diagnosis, surgical management and post-operative care.

References:

[1] Markell KW, Renz EM, White CE, Albrecht ME, Blackbourne LH, Park MS, et al. Abdominal complications after severe burns. J Am Coll Surg 2009;208:940–7.

[2] Ivy ME, Possenti PP, Kepros J, Atweh NA, D’Aiuto M, Palmer J, et al. Abdominal compartment syndrome in patients with burns. J Burn Care Rehabil 1999;20:351–3.


Biography:

Charles Meares is an unaccredited trainee at Royal North Shore Hospital, Sydney.

Myth Busting: What Works Best for Your Scar?

Miss Ashlee Cardey1, Mrs Rosemary Kendell1, Mrs Fiona  Poelchow1,2, Dr Fiona Wood1,2

1State Adult Burns Unit Wa – Fiona Stanley Hospital, Murdoch, Australia, 2Fiona Wood Foundation, Murdoch, Australia

Abstract:

As Occupational Therapists working in the State Adult Burns Unit of Western Australia, a substantial part of our role involves providing comprehensive education on scarring and evidence based interventions that optimise scar outcomes for our patients.   We often find that patients are presented with conflicting information and incorrect advice from friends, family, advertising campaigns and, at times, other health professionals, as to what can help improve a scar. This presents a challenge as we must then compete with this information to correctly advise and arm our patients with evidence supported education and best practice interventions to obtain a good scar outcome.

From essential oils to egg whites, we’ve been asked about it all… but do these ‘treatments’ actually have any benefit? Could they potentially have an adverse effect? What is it that actually helps improve a scar’s appearance or texture?

This poster aims to highlight and dispel some of the common myths and beliefs surrounding treatments for scarring that we routinely encounter in our patient interactions. The poster will be designed as an educational, quick reference tool that provides answers to some of the most common patient concerns regarding scarring, whilst highlighting the most appropriate and evidenced based interventions. By researching and further understanding the various products and treatments that claim to improve a scar, as health professionals we can confidently provide the correct advice and maximise patient outcomes.


Biography:

I am an Occupational Therapist working in the State Adult Burns Service at Fiona Stanley Hospital in Western Australia.

I graduated university in 2014 and have worked in various areas across the acute hospital setting. I have a particularly keen interest in burn care and scar management and hope to continue working in this area long term.

M.I.C.E. Project – INTRODUCING DIGITAL SOLUTIONS FOR CLININCAL MANAGEMENT AND QUALITY IMPROVEMENT

Mr Graeme McLeod1, Professor Fiona Wood1, Mr Aaron  Berghuber1

1Fiona Stanely Hospital – WA Department Of Health  , Palmyra Dc, Australia, 2Fiona Wood Foundation, Palmyra Dc, Australia

Abstract:

BACKGROUND

Mobile devices provide many solutions to aid and manage clinical decisions and workloads. They’re readily accessible and offer quality forms of instant communication. Smartphones and social media are increasingly being used for clinical handovers and to share images of patients.  With no record of consent and bypassing the medical record, this practice breaches statutory law, hospital policy, and patient privacy and further exposes clinician & hospital to unacceptable risks / penalties.

The Mobile Image Communication Exchange (MICE) mobile platform, aims to be an efficient and secure solution to these issues.

METHOD

A state-wide Burns Unit in Australia together with CSIRO developed MICE, using an agile approach in the clinical environment; clinicians and software developers worked side by side providing constant feedback and rapid software updates. Key stakeholder engagement assisted in directing project.  User responses were collected after each occasion of use.

RESULTS

Proof of Concept:  126 images (45 patients) with consent and clinical correspondence were captured through MICE, and sent to the medical record – not stored on clinician’s phones.  All images were rated by clinicians as adequate quality to make a clinical decision.

MICE project has since been nominated for 2018 WA Health Excellence Award and a further pilot with a view to vertically scale across Health has been granted.

DISCUSSION

MICE has shown mobile technology can be safely used to expedite clinical care by providing a secure platform where images can be safely captured/shared. MICE facilitates: transfers, ongoing management of wounds /scars and is transferable across disciplines.


Biography:

Graeme has been working in the State Adult Burns Unit since May 2015, as an MDT Officer, and also as a member of the Digital Innovation Team with the Fiona Wood Foundation.  Graeme’s role has supported the introduction of innovative quality improvement solutions to improve the efficiencies of the Unit, the Hospital and the Department.

Kiss and Swell

Mrs Kerry Millhouse1, Ms Rebecca Schrale2

1Royal Hobart Hospital, Hobart, Australia, 2Royal Hobart Hospital, Hobart, Australia

Abstract:

It is widely recognised that burn related immunosuppression can result in the infection of facial burns which in turn leads to prolonged healing and an increase in adverse outcomes (Wurzer et al: 2017). Herpes Simplex Virus, (HSV), is one such infection, and one that poses a difficult diagnosis with Herpes viruses displaying clinical features involving skin loss that can mimic the initial burn injury (Crowley: 2017). Studies suggest reactivation rates of latent HSV in facial burn injury patients being around 25% (Haik et al: 2011) whilst also recognising the possibility of primary HSV infection within this population (McGill: 2000).

The following case study discusses one such primary HSV infection which prompted a change in screening practices with the RHH, and poses the question what education should be provided to reduce infection rates of HSV within our facial burn population.

References

Crowley, T., and Stevenson, S., 2017, Herpes Zoster Masquerading as a Chemical Burns Secondary to Hair Dye, Journal of Burns Care, Volume 38, Issue 2, pp.580

Haik, J., Weissman, O., Demetris, S., Hadar Israeli, B., Alon, L., Tessone, A., Zmora, N., Zilinsky, I., Winkler, E., Eyal, G., Shy, S., 2011, Is prophylactic acyclovir treatment warranted for prevention of herpes simplex virus infections in facial burns? A review of the literature, Journal of Burn Care, Volume 32, Issue 3, pp.358

McGill, S., Cartotto, R., Herpes Simplex virus infection in a paediatric patient: case report and review, Burns: Journal of the International Society for Burn Injuries, Volume 26, Issue 2, pp.194

Wurzer, P., Guillory, A., Parvizi, D., Clayton R., Branski, L., Kamolz, L., Finnerty, C., Herndon, D., Lee, J., 2017, Human Herpes viruses in burn patients: A systematic review, Burns, Volume 43, Issue 1, pp.25


Biography:

Registered Nurse, Tasmanian Burns Unit, Royal Hobart Hospital

Assessment of Itch: What Tools Are Available?

Dr Sam Hamilton1, Dr Katherine Davis1, Mr Nanda Kandamany1

1Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Sandy Bay, Australia

Abstract:

Background

It has been found that up to 93% of adult burns patients report itching (Nedelec B & LaSalle L, 2018). The ISBI Practice Guidelines Committee (2016) recommends the first stage in the management of itch is to assess the intensity, a task that can be particularly challenging in children. We aim to provide a brief overview of the assessment tools available to assist in the evaluation of itch in burns patients.

Method

A comprehensive search of Pubmed was performed using broad search terms.

Discussion

There are seven different tools available for the assessment of itch which have been validated in an English language population. There is no consensus on a gold standard evaluation tool to date (Nedelec B & LaSalle L, 2018).

The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) are commonly used in the evaluation of itch, simply giving a number or picture to “itch severity”, similar in use to a pain scale. The Itch Man, a five-point Likert scale, works on similar principles (Morris V et al, 2012), and is useful in the paediatric population. The Toronto Paediatric Itch Scale, developed by Everett et al (2015) is for use on children under five years old. It is observational, with care providers monitoring behaviour and applying to a five-point scale. Unfortunately, it has only moderate inter-observer agreement and may not be overly reliable.

There is far more to the impact of itch than just the severity on quality of life, with episode duration and frequency being important factors (Nedelec B et al, 2012). The 5-Dimension (5-D) Itch Scale (Elman et al, 2009) considers degree duration, direction, disability and distribution of itch, and has also been modified to a 4-Dimension Scale (Amtmann et al, 2017). The Burns Itch Questionnaire (Van Loey et al, 2016) uses itch severity, sleep interference and daily life interference to impact of post-burn itch.

Conclusion

In the measurement of itch, it is important to consider factors other than just intensity. There are several validated tools to assist in the assessment of itch.


Biography:

Sam is currently a surgical RMO at the Royal Hobart Hospital. He has a strong interest in plastic surgery and burns management.

 

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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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