The Iceberg Effect: The hidden morbidity of burn injuries in patients with sensorimotor deficits

Dr Michael Taylor1, Dr Hannah Woodford2, Dr Monique  Bertinetti1

1Children’s Hospital Westmead, Westmead, Australia, 2Nepean Hospital , Penrith, Australia


Introduction: Children with sensorimotor deficits present treating teams with additional complex challenges in the coordination of their care.
The epidemiology of burns in children with sensorimotor deficits is anecdotally established to be more prevalent, complex and resource intensive, however minimal data of the incidence and sequelae has been collected.

Method: We performed a 15 year retrospective analysis of all paediatric burn patients under the age of 16 in the NSW ACI database. A cohort identified to have sensorimotor deficits including cerebral palsy, trisomy 21, spina bifida, global developmental delay, and neural-sensorimotor deficits resulting from trauma, was analysed against a control population.
The outcomes measured included TBSA, mechanism, length of stay (LOS), graft and re-graft rates, wound infection, additional visits to theatre, ICU/ventilation requirements, and outpatient follow-up. Linear regression was used to analyse the correlation between the presence of sensorimotor deficit and subsequent outcomes.

Results: 13,011 burn injuries were identified. 95 occurred in patients with an established sensorimotor deficit.
The sensorimotor deficit cohort was older (6.93 years (±4.1) vs 4.0 (±3.9)), had a greater TBSA (4.72% (±10.3) vs 2.48% (±3.9)) and an increased LOS (8.6 days (±13.1) vs 3.1 days (±7.9)) when compared to the control group. 48.5% of cohort patients required more than 1 nights admission. Flame burns were overrepresented in the cohort 11% vs 6%.
6% of cohort patients required ICU admission, and 2.1% required intubation and ventilatory support, compared to only 1% and 0.08% respectively in the control group.
Grafting was required in 39% of sensorimotor deficit patients, opposed to only 19.9% in the control group. Regrafting and wound infection rates were 3 times more likely in the cohort group.

Conclusion: Children with sensorimotor deficits have a higher TBSA, are at greater risk of complications, and experience prolonged and more complex admissions when compared to their non-disabled peers. Future research into improving care and targeted prevention strategies is required for this resource rich, high-risk group.


Dr Michael Taylor is a Paediatric Surgery SRMO at the Children’s Hospital Westmead. His research interests lie Paediatric Surgery, Trauma, and Burns.

Heart Rate as an Isolated Fitness Indicator: is it time to eradicate Age and Gender Considerations in the Burn Injury Patient Demographic

Dr Danika Jurat1

1Fiona Stanley Hospital, Murdoch, Australia



To determine if maximum heart rate and subsequent recovery time to baseline correlates with participant fitness by undertaking a Steady-state Cycle Test in the healthy adult population. Fitness will be determined by a combination of the International Physical Activity Questionnaire and participant’s maximal oxygen uptake (VO2 max) during the Astrand-Rhyming Cycle Ergometer Test. If indicative, the Steady-state Cycle Test will then be trialled in the burn injury patient population. The Steady-state Cycle Test is proposed due to:

  1. The submaximal nature of the test
  2. Ease of test administration

iii.            Ease of result measurement

  1. Reduction of heart rate confounders in a metabolic injury
  2. Removal of the subjective nature of self-reported fitness evaluation

If the sole measure of heart rate is a successful indicator of fitness, this would be a simple and appropriate test to administer to patients on admission to the Burns Unit, allowing guidance on management and projected recovery.

Design: Observational study

Setting: State Burns Unit of Western Australia, Fiona Stanley Hospital

Subjects: Healthy adults aged between 18 and 65 years.

Intervention: 6 minute cycle test at 75 watts at 50 rpm.

Main measures:

  • Maximum heart rate at the six minute mark of the Steady-state Cycle Test.
  • Recovery time to baseline post completion of the Test.
  • Fitness:

–              Self-reported as per the IPAQ.

–              Maximal oxygen uptake (VO2 max) determined by the Astrand-Rhyming Ergometer Cycle test.


Hypothesized outcome: that participants who achieve a lower heart rate and faster time to recovery will have higher scores on the IPAQ and maximal oxygen uptake, indicating higher baseline fitness, regardless of age and gender.


Danika is a third year resident medical officer at Fiona Stanley Hospital with a keen interest in Plastic Surgery, particularly Burns.

Autologous skin cell suspensions in partial thickness burn injury management: A Systematic Review.

Dr Anjana Bairagi1, Dr Bronwyn  Griffin1,2,3, Prof Steven McPhail4,5, Prof  Roy  Kimble1,2,3,6, Dr Zephanie Tyack1,4,5

1Centre for Children’s Burns & Trauma Research, Brisbane,, Australia, 2Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Brisbane,, Australia, 3School of Nursing & Institute of Health and Biomedical Innovation (IHBI), Queensland University of Technology, Brisbane,, Australia, 4School of Public Health and Social Work & Institute of Health and  Biomedical Innovation, Queensland University of Technology, Brisbane,, Australia, 5Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia, 6Faculty of Medicine, University of Queensland, Brisbane,, Australia



Acute partial thickness burns are commonly of mixed depth and continue to be a challenge to manage due to the potential for unacceptable scar outcomes. In the past four decades, autologous skin cell suspensions (ASCS) have progressed remarkably from simple origins of serial keratinocyte cultures to a variety of formulations available today.  The objective of this systematic review was to evaluate the effectiveness and type of ASCS used in the management of partial thickness burn injuries.


In April 2019, EMBASE, Google Scholar, MEDLINE, Web of Science, grey literature and relevant journals were searched.  The inclusion criteria for eligible studies (n=2851) were randomised controlled trials (RCT) and pilot RCT of human partial thickness burns and donor sites managed with non-cultured ASCS. Two independent researchers used Covidence® for screening, quality assessment and data extraction. The Cochrane Risk of Bias and Grading of Recommendations Assessment, Development, and Evaluation tools were used for risk of bias assessment.


Five included studies, conducted in Australia, China, Italy, Switzerland and USA, had mostly adult participants (n=4 studies). ASCS was prepared with RECELL® autologous cell harvesting device (n=4 studies) and a laboratory method (n=1 study). ASCS has been reported as effective to reduce wound re-epithelialisation time (n=4 studies), improve scar quality (n=2 studies), as well as reduce donor site area (n=2 studies) and pain (n=3 studies).


ASCS have been used predominantly in adult populations. The dearth of studies regarding the management of paediatric partial thickness injuries with ASCS justifies further research in this population.


Dr Anjana Bairagi is a paediatric surgeon undertaking a PhD with the  Centre of Children’s Burns & Trauma Research Group. Her research is evaluating non-cultured autologous skin cell suspensions in the management of partial thickness burn injuries in children.

Regional variations in burn first aid treatment. Does where you live relate to mortality?

Ms Jennifer Gong1, Dr Lincoln Tracy1, Associate Professor Dale Edgar2,3, Professor Fiona Wood2,4, Ms Yvonne Singer5, Professor Belinda Gabbe1,6

1School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, 2State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Australia, 3Burn Injury Research Node, The University of Notre Dame, Fremantle, Australia, 4Burn Injury Research Unit, University of Western Australia, Perth, Australia, 5Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Australia, 6Heath Data Research UK Institute, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom


Background: Early intervention with burn first aid has shown to improve clinical outcomes and lower mortality rates. This study aimed to describe the variation in burn first aid practice and patient characteristics to explain regional differences in first aid application.

Methods: Cases from the Burns Registry of Australia and New Zealand (BRANZ) from July 2016 to June 2018 were extracted to examine the characteristics and outcomes of patients who do and do not receive burn first aid within three hours of injury. Admissions to Australian burn centres were stratified by socioeconomic status and geographic remoteness to explore regional variation in first aid treatment.

Results: 6,554 cases were recorded in the BRANZ during the study period. Burn first aid was applied to 76% (n=4,991) of cases. When burn first aid was applied, 79% (n=3,774) of cases received best practice first aid, defined as 20 minutes of cool running water within three hours of injury. A greater portion of patients in the highest quintile of socioeconomic advantage (22%) received best practice burn first aid compared to those in the lowest quintile (15%). Patients residing in major cities were more likely to apply best practice burn first aid compared to those in regional and remote areas (64% vs 36%).

Conclusion: This paper provides contemporary data about burn first aid. Best practice burn first aid was more prevalent in patients from areas of greater socioeconomic advantage and major cities. This may be explained by greater health literacy, and barriers in accessing a water source.


Jennifer Gong is a research assistant in the School of Public Health and Preventive Medicine at Monash University, where she currently works on the Burns Registry of Australia and New Zealand (BRANZ). She is also a biostatistics and epidemiology teaching associate within the school.  Jennifer is on track to complete her Master of Public Health this year, specialising in health economics and economic evaluation, with a minor in biostatistics.

The accuracy of burn TBSA estimation in referrals to a regional burns unit

Dr Alexandra Carswell1, Dr  Rahul Jayakar1, Dr Joseph  Chen1, Mr  Christopher Adams1

1Dept of Plastic and Reconstructive Surgery, Hutt Hospital, Hutt Valley DHB, Lower Hutt, NZ , Lower Hutt, New Zealand


Background: Estimation of burn size is an essential first step in the management of the burned patient. Accurately determining the total body surface area (TBSA) determines management, as it guides volume of fluid resuscitation and referral to specialist burns units.

Aim: This audit was performed to document the accuracy of burn TBSA estimation by referral centres when referring patients to our regional burn unit; and identify any factors that may impact on this.

Methods: Retrospective review of consecutive patients referred to a regional burns centre for management of moderate sized burns from 2013 – 2017. Data was retrieved from a prospectively maintained burns database. Inclusion criteria: All burns managed at HVDHB that were estimated or referred as >10%TBSA. Primary Variables were: demographics, method of injury, estimated TBSA, final calculated TBSA, time to arrival, fluid resuscitation accuracy and 30 day complications.

Results: 80 patients were included in our study. There were 14 children and 66 adults.  Mean TBSA burn referred was 19% TBSA (median =15, range 7-65 %). There was a trend to overestimate burn size. This was significant when burn was >20% TBSA for adults (p = 0.0003). This resulted in over prescription of resuscitation fluids by some centres.

Conclusions: There are inaccuracies in referral TBSA estimations, with a trend to overestimate. This audit did not reveal factors impacting on this, but suggests the need for further, larger reviews, to assess the effect this overestimation has on patient outcomes.


Dr Alex Carswell graduated from the University of Otago medical school in 2017. She is currently a house surgeon at the Plastics and Reconstructive Surgery Department at Hutt Hospital. She has an interest in the care of the burned patient, including the effect that initial estimation of burn TBSA ultimately has on patient care.

Recurrent self-inflicted burns – A fourteen-year retrospective analysis in a single tertiary level burns unit

Dr Hardip Chahal1, Dr Derek  Liang1, Dr Antony Henderson1, Dr Aruna Wijewardena1, Dr John Vandervord1

1Royal North Shore Hospital, St Leonards, Australia



Self-inflicted burns are commonly admitted to burns units worldwide. These patients are often challenging to manage due to underlying psychosocial issues and multiple representations. The majority of these patients have an underlying psychiatric condition and require multi-disciplinary input. A small subset of these patients present to hospital with recurrent self-inflicted burns. The aim of this study was to explore the factors that contribute to self-inflicted burns readmissions and provide suggestions for treatment pathways.

Method: Self-inflicted burns patient data was drawn from a computerised registry at a single tertiary centre. Data analysis between 2004 to 2019 revealed a total 8849 patients managed for acute burns. 193 (2.1%) were identified as self-inflicted burns. Of these patients 15 (0.2%) were identified to have previous self-inflicted burns and their cases were examined retrospectively.


All patients presenting with self-inflicted burns were reviewed by psychiatric services and had an underlying mental health disorder. Of the recurrent self-inflicted burn patients 12 were females and 3 were male. 75 burns were treated amongst this group at a range of 2 to 20 burns per patients. Chemicals were the most frequent method of burning (69%). Average total body surface area (TBSA) for these burns was 1.6% (range 0.1 – 8% TBSA). Patients had varying levels of psychiatric follow up post discharge.


Borderline personality disorder, female gender, history of substance abuse and developmental trauma are common risk factors for representation. A coordinated treatment pathway involving surgical and early psychiatric input with consistent follow-up is essential in managing recurrent self-inflicted burns patients.


Resident medical officer, Royal North Shore Hospital, Plastic and Reconstructive Department

Electrical burns in children – 15 years single tertiary trauma centre experience

Dr Ana Galevska1, Dr  Sonia Tran1, Dr Monique  Bertinetti1, Prof  Andrew AJ Holland1

1Department of paediatric surgery, Westmead Children’s Hospital, Westmead, Australia


Electrical paediatric burns are relatively rare but can have devastating complications and long-term impact. The aim of this study is to describe the presentation, epidemiology, treatment and complications of electrical burn injuries in children. For the purpose of this study the BRANZ (Burns Registry of Australia and New Zealand) database was retrospectively reviewed since its inception in June 2004 until June 2019. Case notes were reviewed for all patients under 16 years of age with electrical burns that presented at single tertiary burns centre and outcomes reviewed. To date, 72 children with average age of 6.5 years and Male to Female ratio of 1.4:1 have suffered electrical burns. The majority of the burns were low voltage and the most common site were the hands, almost half of the children (48%) did not have adequate first aid. Majority of the cases were managed conservatively and with close observation and skin graft was the most common procedure in those that required surgical intervention.


Currently employed as paediatric surgical registrar at Westmead Hospital with strong interest in research

Diabetic foot burns – A retrospective analysis of epidemiology and protocols

Dr Jason Diab1, Dr Andrea Issler-Fisher1, Mrs Miranda Pye1, Ms Christine Parker1, Prof Peter Kennedy1, Prof Peter Haertsch1, Dr Justine O’Hara1, Professor Peter Maitz1

1Concord Burns Unit, Concord Hospital, Concord, Australia



The International Diabetes Federation estimates 1.1 million people aged between 20 and 79 years with diabetes in Australia  .  Diabetic foot burns are a common clinical presentation that poses a challenge for teams to manage requiring a multidisciplinary approach.  Our aim is to identify and classify epidemiological trends of diabetic foot burns at Concord hospital from 2014 – 2019. The secondary objective will examine the ways a diabetic foot burn protocol can be implemented to provide patient education on diabetic foot burns and reduce costs.


A retrospective audit from 2014 – 2019 at Concord General Repatriation Hospital Burns Unit summarised patient demographics, burn injury, diabetic status, operations and length of stay. All foot burn injuries from 2014 – 2019 of all ages and gender that attended Concord burns hospital were included in this study. A statistical analysis using SPSS was used to analyse the data.


There were 135 patients whom presented with diabetic foot burns representing 15.2% of all foot burns. The average age was 60.25 years with winter being the most affected season. The most common mechanism of injury was contact (38.5%), followed by scald (34.1%). There is a strong statistical relationship with first aid and the extent of burn surface area such that they are dependent and statistically associated from the data [χ2 (5df) = 23.331, p =< 0.001; Cramer’s V = 0.416, p < 0.001]. The average total burn surface area (TBSA) was 1.78% with 26.67% required grafting. Multiple regression analysis was undertaken to predict length of stay from age, gender, TBSA, mechanism of injury, sensory modality, and seasons. From the model, TBSA, sensory modality and gender were statistically significant for increased length of stay F (5,53) = 4.707, P=0.001, R2 = 0.308.


With the increase of diabetes, our multidisciplinary approach to diabetic foot care should include nursing, medical and surgical disciplines to identify patients at risk. The data highlights that a focus on prevention and education for diabetes is central to optimize glycaemic control and burn management, whilst providing a multidisciplinary network on discharge.


Jason is a SRMO at Concord Burns Unit with experience in health research, craniofacial and plastic surgery.

Vitamin D and burns – A review of the literature and protocols

Dr Jason Diab1, Dr David Khaicy1, Dr Fergus Davidson1, Prof Peter Maitz1, Dr Winnie Hong1

1Concord Hospital, Concord, Australia



Vitamin D deficiency is observed in critically ill patients and has been related to limited sunlight exposure or the magnitude of injury. It is associated with calcium homeostasis and bone mineralization, osteopenia, osteoporosis, and fractures . It has gained considerable amount of interest in the medical literature and the effects of vitamin D on health outcomes are still unclear. In specific subpopulations such as burns, the hypercatabolic response and systemic inflammatory response (SIRS) poses a dynamic response from the body that in turn reduces vitamin D, carrier proteins and albumin . The aim is to discuss current understanding of vitamin D and its role in burn patients, the effect of burn injury on vitamin D status, the association of vitamin D levels on outcome and the potential therapeutic value of vitamin D.


A comprehensive literature review was conducted to obtain an understanding of the context, followed by a retrospective audit at Concord hospital from 2017 – 2019. Adult in patients whom suffered a burn were included in the study. Data was obtained from demographic information, severity of burn, medication use and vitamin D status. SPSS was used to analyse data.


Patients admitted to the unit over the two year period did not all have vitamin D levels measured. Although, there is variation in the types of burns and length of stay, in the most severe burns there levels were reduced over an extended period of admission. The statistical relationship regarding this outcome is pending.


There may be contributing factors to vitamin D deficiency in patients with severe burns including pre-exisiting deficiency, prolonged hospitalization and lack of sun exposure. The role of Vitamin D is equivocal at this stage with ongoing research needed.


Jason is a SRMO at Concord Burn Unit with an interest in public health prevention and epidemiology in burns.

Foot burns – A retrospective review of clinical characteristics and outcomes from 2014 – 2019

Dr Jason Diab1, Dr Andrea Issler-Fisher1, Mrs Miranda Pye1, Ms Christine Parker1, Dr Justine O’Hara1, Prof Peter Kennedy1, Prof Peter Haertsch1, Prof Peter Maitz1

1Concord Hospital, Concord, Australia



Albeit a small percentage of the body affected (3.5%), foot burns can have major effects on hospitalisation, length of stay and long term outcomes. Our aim is to identify and classify epidemiological trends of foot burns at Concord hospital from 2014 – 2019. The secondary objective will examine the sub specific groups and how education can be implemented in a clinical setting.


A retrospective audit from 2014 – 2019 at Concord General Repatriation Hospital Burns Unit summarised patient demographics, burn injury, operations and length of stay. All foot burn injuries from 2014 – 2019 of all ages and gender that attended Concord burns hospital were included in this study. A statistical analysis using SPSS assessed the relationship between linear data and correlation based on a level of significance set at p value of 0.05.


There were 886 patients whom presented with foot burns to the unit. The average age was 42.76 years with men (66.9%) more affected than females. The most common season for foot burns was summer. The most common mechanism of injury was scald burn (54.7%) followed by contact (17.8%). 15.2% of the cohort were diabetics. 80.1% of cases were not admitted and reviewed within the outpatient setting.  There was a statistically significant mean difference between diabetics and non-diabetics for TBSA [t(884) = 2.073, p =0.038], number of operating sessions [t(884)=-2.123, p=0.034], length of stay [t(884)=-2.430,p=0.015], gender [t(884)=4.547, P>0.001] and first aid adequacy [t(884)=6.926, p< 0.001]. Multiple regression analysis was undertaken to predict length of stay from age, gender, TBSA, mechanism of injury, season, and diabetes. From the model, TBSA, season and diabetes were statistically significant for increased length of stay F (6,879) = 34.051, P=0.02, R2 = 0.189.


Foot burns poses a challenge for teams to manage requiring a holistic approach of care. Its morbidity and complications can require ongoing visits and operations with risk factors that can be optimized early on in treatment protocols.


Jason is a SRMO at Concord Burns Unit with an interest in public health epidemiology prevention in burns.


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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