Burns and organ donation? Compatible?

Abstract:

Have you ever assumed burns patients are not suitable for organ and tissue donation?

Did you know 1400 people around Australia are currently waiting for a transplant?

Organ donation conversations are crucial, not only to save and improve the lives of transplant recipients, but empower patients and their families during end of life (EoL) planning.

The National consensus statement for end-of-life care and associated best practice standards, highlight the importance of identification of all potential organ donors through routine EoL referrals to DonateLife and the skilled conversations with families that follow.  In collaboration with DonateLife, ED and ICU staff can provide families with timely, accurate information to empower them to make an informed and enduring organ donation decision.

For patients with burns or complications from burns that are deemed futile, DonateLife should be consulted for exploration of donation suitability.  The following two case studies show the varied presentations that could offer donation potential:

  • A 63 year old woman with 12% TBSA circumferential burns to her lower limbs with sepsis and multiorgan dysfunction. Futility was determined during her 38 day ICU admission, with family support she donated her lungs successfully to a grateful recipient.
  • A 50 yo female suffering 60% burns in a house fire with OOHCA with unknown downtime. Post debridement in theatre she demonstrated fixed dilated pupils, she was declared brain dead the following day with a Nuclear medicine scan.  Her family supported donation of both her kidneys to two recipients.

Author: Kate Hicks and Rebecca Schrale

Acknowledgements: DonateLife Victoria


Biography:

Kate Hicks is a Donation Specialist Nursing Coordinator working for DonateLife Tasmania.

Sequalae of full-thickness burn penetrating to muscle: an unusual and insidious manifestation of rhabdomyolysis and compartment syndrome.

Dr Julian Smyth1, Dr Andrea Issler-Fischer1,2,3, Dr Tim Wang, A/Prof Peter Haertsch1,3, Prof Peter Maitz1,2,3

1Burns Unit, Concord Repatriation General Hospital, Concord, Australia, 2ANZAC Research Institute, Concord Repatriation General Hospital, Concord, Australia, 3University of Sydney, Camperdown, Australia

Abstract:

Rhabdomyolysis, due to direct thermal injury to muscle, is rare. We describe the initial management of a forty-seven year old gentleman with rhabdomyolysis and compartment syndrome resulting from severe thermal scald/contact injury.

A forty-seven year old male presented to our Unit via primary rotary-wing retrieval following a 32%TBSA thermal injury to his bilateral lower limbs, buttocks and periumbilical region. He had been partially submerged in molten asphalt (approximately 180 degrees Celsius) for an estimated 120 – 300 seconds before he could extricate. Adequate first aid was administered by first responders. He was intubated and sedated due to significant analgesia requirements and arrived at our centre approximately ninety minutes following injury.

On arrival the patient was tachycardic and normotensive. On assessment, he presented with full-thickness circumferential bilateral lower limbs burns up to his superior thighs, his calves were tense bilaterally, and his feet cold and pulseless. An indwelling catheter was placed revealing frank myoglobinuria. Immediate recognition for need for bilateral leg fasciotomies was made. Escharotomies were performed in the interim. Operative findings revealed direct thermal injury to the superficial portions of all leg musculature, particularly the peroneal compartment. Perfusion was restored to the bilateral lower limbs following release of all compartments and the patient recovered in ICU post-operatively. The patient has made an excellent functional recovery and is now independently ambulating.

Rhabdomyolysis and compartment syndrome may be life or limb threatening. This unusual mechanism of injury highlights the need for clinicians to maintain high levels of clinical suspicion and treat these developing syndromes aggressively.


Biography:

Julian was the serving burn surgery registrar during when the patient for discussion was admitted.

Perils of tissue adhesive – A Case Study

Dr Thomas Meares1

1Gold Coast University Health, Mermaid Beach, Australia

Abstract:

Introduction:

37-year-old male presented to Gold Coast University Hospital Out Patients department 1 year post DFSP excision and split skin graft to his left lateral thigh. His primary complaint was three tender, hard, non-mobile lesions within the superior graft border.

Initial excision was complicated by wound breakdown and wound dehiscence leading to a meshed 1.5x SSG to the patients left lateral thigh.

History:

Patient reported initially noticing three 3x2mm hard, firm and non-mobile lesions approximately 4 months after grafting. Was reassured by a LMO that it was likely slow scar maturation. Only during his 3-monthly review at the 1-year mark did the patient alert the Plastics team to his concerns.

Differential diagnosis included recurrence, neuroma, foreign body or epidermal cysts.

Treatment:

Patient was highly anxious regarding recurrence, so decision was made to proceed to excision and direct closure. During the operation it was noticed that the three lesions (figure 1) were violet in colour, non-uniform in shape and bared a striking resemblance to tissue adhesive commonly used to affix skin grafts.

Diagnosis:

Histopathological diagnosis was highly suspicious for cyanoacrylate and inflammatory tissue.

Learning objective:

Though this is one small case study, it highlights that tissue adhesive is not just the benign instrument that we so commonly use. Its increased use both in the operating theatre and in the emergency department must be in tempered with great care as highlighted by this return to theatre for something so avoidable.


Biography:

Dr Thomas Meares is currently working at the Gold Coast University Hospital as a Plastics PHO

History of the Humby Knife

Dr Thomas Meares1

1Gold Coast University Health, Mermaid Beach, Australia

Abstract:

Though Mr Thomas Graham Humby was not the first to employ a grafting knife his contribution to burns treatment and care cannot be understated.

The first recorded description of the Humby knife as we use today comes from a small article in the 1934 BMJ edition that describes an “apparatus for skin graft cutting”. His initial design was simply to add a roller to the already well-known Blair (1930) grafting knife that could be calibrated to adjust the grafts thickness. Simple yet highly effective. His rigid frame was strapped to the skin and “tiny needles…at either end pierced the skin…[which] allow stretching of the skin surface”. A knife “seven inches long and wafer thin” is then inserted into the framework and slide along the taught skin. Within the next two years Humby had further modified “graft cutting razor, “discarding the rigid framework and solely relaying on the pressure of the knife to determine the width of the graft.

Interestingly during this time of apparatus modification, Humby only made mention of its ability to take full thickness grafts: “In thickness, color and small tendency to contract, the full thickness graft is the most suitable one in 99% of cases”. Though Graham Humby wrote seven papers during the 30’s and 40’s only 3 reference modifications to the original framework idea.  Figure 1 shows the initial apparatus to the 1936 modification while figure 2 emphasis the linear progression of grafting knife modifications.

References:

Clarkson P. The Humby. Br Med J. 1952;2:1101

Humby G. Modified Graft Cutting Razor. Br Med J. 1936;2:1086

Humby G. Apparatus for Skin Grafting. Br Med J. 1934;1:1078

Chick LR. Brief history and biology of skin grafting. Ann Plast Surg. 1988;21:358–65


Biography:

Dr Thomas Meares is a current Plastics PHO at the Gold Coast University Hospital

The Understanding of Acute Burns Management in the Emergency Department Setting : The Perspective from Royal Hobart Hospital

Dr Jen Martins1, Dr Thomas  Whitton1, Mr Andrew Castley1

1Royal Hobart Hospital, Hobart, Australia

Abstract:

The management of burns in acute setting to reduce the depth and progression of the burn is essential. Most patients will present to an emergency department post acute burn injury for treatment. Thus,  it is imperative that patient’s receive optimal acute burns care in this setting.

As a result, it is essential that emergency room doctors have a good understanding of acute burn care. A survey was undertaken by 20 emergency room doctors at the Royal Hobart Hospital.

The results of the survey did show areas of weakness in their knowledge in acute burn management. This deficit in knowledge extended over all levels of training, but It was most evident in junior doctors. Such deficits included the uncertainty of the duration of first aid and time period, the necessity of prophylactic tetanus, assessing the severity & extent of the burn and dressing management.

Therefore, this survey identifies the need to improve acute burns management education for emergency room doctors to ensure that patients presenting with acute burns receive 1st line  care.

Reference

1) Middelkopp E et al. 2015. Response to Burns in the Elderly: What is pathophysiology & What is physiology? EbioMedicine. 2(10): 1314-1315.


Biography:

Jennifer Martins is a plastics trainee from Victoria but originally for Western Australia. She is currently working at the Royal Hobart Hospital for the plastics department.

Acute Burns Admissions in the Elderly Population: A Royal Hobart Hospital Perspective from 2014-2018

Dr Jen Martins1, Dr Thomas Whitton1, Mr Andrew Castley1

1Royal Hobart Hospital, Hobart, Australia

Abstract:

Australia has an ageing population. As a result, there are greater number of elderly patients presenting with acute burns. Such patient are much more medically complex with multiple co-morbidities, poor wound healing capacity and low reserves to traumatic insults. From data obtained from the Royal Hobart Hospital’s burns unit from 2014-2018, the rates, causes and outcomes of acute burns in the elderly were identified. The overall rates of burns admissions in the elderly population ( i.e. patients over the age of 60 years) have gradually increased over the last 5 years from 12 to 20 in 2014 and 2018 respectively. In addition, 57 elderly patients were treated in total during that period.  Fifty six patients sustained their burns by accident and the most common cause was from flame burns, followed by scalds. Post management, 11 patients required admission to another centre (i.e. rehabilitation centre or another acute hospital) & one patient died. This data identifies the rising need for geriatric input for greater number of elderly patients with acute burns. It also illustrates the need for better education in the elderly population regarding burn prevention, specifically relating to scald and flame burns. Lastly, elderly patients are much more likely to be discharged to another institution post injury. Thus, it is essential to that these factors into account to aid the development of better burn prevention and management in the geriatric population.

References:

1) Khan AA et al. 2007. The Bradford Burn Study: the epidemiology of burns presenting to an inner city emergency department. EMJ. 24(8): 523.

2)Laing JH et al. 1991. Assessment of burn injury in the accident & emergency department: a review of 100 referrals to a regional burn unit. Ann R Coll Surg Engl. 73(5):329-331

Biography:

Jennifer Martins is a SET 1 Plastics Registrar, currently at the Royal Hobart Hospital.

Electric contact burns of neck: Case series and proposal of management protocol.

Dr Sandeep B1, Dr Ramesh Sharma1, Dr Chris  Song1, Peter Meier1

1Fiona Stanely Hospital, Perth, Australia

Abstract:

Electrical contact burns results in devastating soft tissue injuries. They require surgical debridement leading to loss of function or complete removal of the part. Even though the contact area is less, this devastation is due to increased heat production along with electroporation and protein denaturation.

In literature we can find electric burns leading to bowel gangrene, arterial rupture, tracheoesophageal fistula etc(2). Neck contact burns have been rarely reported and discussed in literature.

We report case series of electrical contact burns of neck and propose a management protocol.

Materials and methods:

Electrical contact burns cases admitted from 2015- 18 in our institute were analyzed and those who had neck contact burns where included in the study. Mode of presentation, management details including investigations and surgical outcomes were analyzed.

Results:

In the neck, trachea was most commonly involved followed by cervical spine seen in 3 patients each. Other important structures exposed were mandible border(2 cases) , esophagus(1 case), clavicle(1 case), carotid sheath(1 case).

Reconstruction was done using deltopectoral flap in 4 cases, latissimus dorsi flap in 1 case, pectoralis muscle flap in 1 case, local flap cover in 2 cases, NPWT followed by skin grafting in 1 case.

Protocol followed/ Proposed Protocol

Electric contact burn scalp: modes of presentation and management.

Sandeep B1, Chang  Chew1, Dr Kiran Narula1, Dr Satya Swaroop Tripati

1Fiona Stanely Hospital, Perth, Australia

Abstract:

Introduction:

Electrical contact burns are devastating. The contact burns usually occur in the limbs but can occur in other locations like scalp, abdomen, perineum etc. Scalp contact burns are quite commonly seen. We present our case series of 20 patients and their spectrum of presentation and management.

Materials and method

All cases of electric contact burns data were retrieved from 2013 to 2015 data registry. Scalp defect cases were analyzed.

Results:

20 patients scalp electric burns were treated during the time period of 2013 to 15. 18 were male and 2 were female patients. Mean age of presentation was 35.5 years. History of fall from height was there in 5 patients their scalp defect was addressed secondarily. Mean hospital stay during the admission for scalp defect were 38.4 days in acute setting, 12 days in outpatient admission patients. Skin only involvement was seen in 2cases, skin + periosteum in 2 cases, skin+periosteum + anterior table of skull in 12, skin + 2 tables of skull in 2 cases, skin + full thickness skull + pus underlying with dural involvement in 2cases.  After debridement cover was provided by local flaps in 16 cases, 2 patient underwent extracorporeal RAFF, 2 patients required free flap (1-RAFF 1- LD muscle), one case grafting on dura followed by tissue expansion and flap cover was done. Bone defect later requires split calvarial bone reconstruction.

Conclusion:

Electric contact burn of scalp presents in myriad ways with different depth of involvement from skin, calvarium, dura, brain matter. This warrants debridement of devitalized anterior or both anterior and posterior cortex of skull, sometimes requiring pus drainage. Coverage of the defect is done with either locoregional flap or if local options absent then coverage is given by free flap.


Biography:

Bio to come

E-cigarette burns: a new age

Dr Thomas Whitton1, Dr Rory Middleton1, Dr Jennifer Martins1

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

Abstract:

Background: E-cigarettes (commonly known as vapes) are an emerging technology worldwide used to deliver a vaporised nicotine solution to be inhaled by the user.  Although their sale is illegal in Australia, their use is rapidly increasing.  A survey in 2016 revealed that 9% of Australian adults have used an e-cigarette, a doubling in use since 2013.  Overseas centres are observing increasing frequency of burns caused by e-cigarettes.  Faulty e-cigarettes cause flame, thermal, blast and alkali burns, usually due to exploding lithium-ion batteries, and also have the potential to cause inhalation injuries, deep-dermal and full-thickness burns.

Method: A literature review was performed through PubMed to identify articles that contained data regarding acute burn injuries caused by the use of e-cigarettes.

Results:  Burns from e-cigarettes most frequently occur in young males.  The upper and lower limbs were most commonly affected, followed by groin, genitalia and face.  The average surface area recorded was 4%, with most burns being mid-deep dermal or full-thickness, and on average, one third of cases required surgical management.  There are no agreed guidelines for the management of e-cigarettes, however following an initial systematic trauma assessment, a thorough assessment of the burn injury should be undertaken, including investigating for a chemical component with pH testing.  Appropriate initial management involves thorough irrigation with water, unless an alkali component is identified, then mineral oil should be used.  Surgical debridement and grafting may be required depending on the burn severity.

Conclusion:  There have only been a small number of burns caused by e-cigarettes reported in Australian burns centres, it is likely that we will see more presentations with burns secondary to their increased usage.  Further understanding of the mechanisms of these burns will facilitate better management.  Furthermore, increased education about the dangers of e-cigarettes is required to aid in prevention of these injuries.

References: 1) Serror K et al. 2018. ‘Burns caused by electronic vaping devices (e-cigarettes): A new classification proposal based on mechanisms.  Burns 44(3): 544-548.


Biography:

Tom Whitton is a RMO at the Royal Hobart Hospital with an interest in surgery, including plastic and burns surgery.

Advances in the treatment of burn scars with intense pulsed light, laser and radiofrequency

Henry Li1, Sally Ng1, Jie Li2, Yixin Zhang2

1 Monash Health, 246 Clayton Rd, Clayton, VIC, 3168, sallykhng@gmail.com

2 Department of Plastic and Reconstructive Surgery, Shanghai Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China

Introduction:

Burn related scarring could lead to functional, aesthetic and psychological consequences for patients, leading to significant morbidity. Light-based therapies, laser-based therapies and radiofrequency have demonstrated promising results in improving the scar quality and reduce pruritis. The objective of this review is to summarise the current literature surrounding laser-based modalities for burn scar management.

Methods:

A review of the current literature was performed by searching PubMed, Medline and Embase databases with MeSH and keyword searches. Observational studies, case reports and series, comparative studies, randomised controlled trials and systematic reviews from between 1995 and 2019 were read, stratified by level of evidence and summarised.

Results and conclusion:

Initially, the immature burn scar is hypervascular, containing oxy-haemoglobin, collagen and water. Therapies that target these chromophores are hence useful in the immature scar. Intense pulsed light is useful in targeting the vasculature of scars and can treat immature scars. The treatment of mature burn scars with lasers involves targeting the dermal architecture. Therapies such as CO2 laser, PDL, Q-switched Nd:YAG and are useful for this. Radiofrequency has also been shown to be a useful adjunct in the management of scars. Light-based and laser-based therapies are effective in improving burn scars with minimal adverse effects and should be included in management protocols alongside other non-surgical options.

 

References:

  1. Zuccaro J, Ziolkowski N, Fish J. A Systematic Review of the Effectiveness of Laser Therapy for Hypertrophic Burn Scars. Clin Plast Surg. 2017;44(4):767-79.
  2. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars. Dermatol Res Pract. 2012;2012:243651.
  3. Sarkar A, Dewangan YK, Bain J, Rakshit P, Dhruw K, Basu SK, et al. Effect of intense pulsed light on immature burn scars: A clinical study. Indian J Plast Surg. 2014;47(3):381-5.
  4. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns. 2010;36(4):443-9.
  5. Douglas H, Lynch J, Harms KA, Krop T, Kunath L, van Vreeswijk C, et al. Carbon dioxide laser treatment in burn-related scarring: A prospective randomised controlled trial. J Plast Reconstr Aesthet Surg. 2019;72(6):863-70.
  6. Willows BM, Ilyas M, Sharma A. Laser in the management of burn scars. Burns. 2017;43(7):1379-89.
  7. Daoud AA, Gianatasio C, Rudnick A, Michael M, Waibel J. Efficacy of Combined Intense Pulsed Light (IPL) With Fractional CO2 -Laser Ablation in the Treatment of Large Hypertrophic Scars: A Prospective, Randomized Control Trial. Lasers Surg Med. 2019.
  8. Cho SB, Lee JH, Lee SH, Lee SJ, Bang D, Oh SH. Efficacy and safety of 1064-nm Q-switched Nd:YAG laser with low fluence for keloids and hypertrophic scars. J Eur Acad Dermatol Venereol. 2010;24(9):1070-4.
  9. Bowes LE, Nouri K, Berman B, Jimenez G, Pardo R, Rodriguez L, et al. Treatment of Pigmented Hypertrophic Scars with 585nm Pulsed Dye Laser and the 532nm Frequency-Doubled Nd:YAG in the Q-Switched and Variable Pulse Modes: A Comparative Study. Dermatol Surg. 2002; 28:714-719
  10. Jang JY, Han JH, Yoon KC, Shin HW, Kim YS, Kim, JK. Early Management of Scars using a 532-nm Nd:YAG Laser. Arch Aesthetic Plas Surg. 2017; 23(2):62-67
  11. Fu X, Dong J, Wang S, Yan M, Yao M. Advances in the treatment of traumatic scar with laser, intense pulsed light, radiofrequency, and ultrasound. Burns & Trauma. 2019; 7:1

Biography:

Henry is a surgical resident at Monash Heath with an interest in plastic and reconstructive surgery.

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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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