Inhalation injury and the upper airway: a case of severe laryngeal scarring, glottis stenosis and dysphagia

Mrs Miriam Voortman1, Mrs Gulsen Ellul1, Ms  Heather Cleland1, Ms Amanda Richards2

1Victorian Adult Burns Service, Melbourne, Australia, 2Epworth Healthcare, East Melbourne, Australia

Abstract:

Long term outcome post inhalation injury to the upper airway is not well reported in the literature. This single case study will explore the long term outcome of a patient with 28% deep dermal burns and severe inhalation injury due to building fire resulting in laryngeal stenosis and airway compromise.
On admission the patient had 3 failed attempts at intubation due to epiglottic oedema and required cricothoracotomy then surgical tracheostomy to secure the airway.
Speech pathology management of upper airway burns included tracheostomy weaning, perceptual voice assessment, Videofluoroscopic Swallowing Study (VFSS) and Fibreoptic Endoscopic Evaluation of Swallowing (FEES).
After decannulation the patient was severely dysphonic and FEES demonstrated nasal adhesions, reduced laryngeal sensation, copious secretions and a patent upper airway. The patient was unable to commence oral intake due to severe dysphagia and a Percutaneous Endoscopic Gastrostomy was inserted.
10 weeks post initial injury the patient developed stridor and exertional dyspnoea while at inpatient rehabilitation. He was seen as an outpatient and was immediately admitted for emergency tracheostomy insertion due to severe subglottic stenosis and posterior glottic stenosis. 12 months post injury the patient continues to have a permanent tracheostomy and is being considered for laryngotracheal reconstructive surgery. He remains severely dysphonic however has resumed regular oral intake.
Key learnings from this case included that close monitoring by speech pathology and ENT is beneficial in identifying early upper airway stenosis. A guideline for airway surveillance will be developed in future to identify patients at risk of laryngeal scarring. Laryngeal scarring will result in persisting dysphonia however severe dysphagia may resolve long term.


Biography:

Miriam is a Senior Speech Pathologist at The Victorian Adult Burns Service and has worked extensively in the field of voice and dysphagia management.

Prevention and Management of Hypothermia in Burns Patients in the Operating Room: a Best Practice Implementation Project.

Mrs Svetlana Kolokolnikova1, Mrs Natalia Adanichkin2, Dr Sandeep  Moola3

1Clinical Nurse, Burns Theatre, Technical Suites, The Royal Adelaide Hospital, Adelaide, Australia, 22 ANZBA Nursing Chair, ANZBA SA Representative, Advanced Nurse Unit Manager, Adult Burns Centre, The Royal Adelaide Hospital,7G154, , Adelaide, Australia, 3Research Fellow, Implementation Science Team, The Joanna Briggs Institute, The University of Adelaide, Adelaide, Australia

Abstract:

Perioperative patients with burn injury are at great risk of hypothermia.
Cancellation or interruption of surgery results in a patient’s multiple additional visits back to theatre for further excisions, prolonged theatre time, excessive use of surgical time and resources.
The aim of this project was to develop and implement the best evidence based protocol on management of hypothermia in burns patients in the Operating Room and thereby improve burns patient management and outcome.
This evidence based implementation project utilises the Joanna Briggs Institute’s Practical Application of clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The PACES and GRiP framework involves three phases.
The first phase included a baseline audit on management of hypothermia in burns patients in operating theatres undertaken in the old Royal Adelaide Hospital.
The second phase involved reflection on the results of the baseline audit and designing and implementing evidence based best practice protocol on management of hypothermia in burns patients in the operating room. Findings from base line audit reflected that preventative actions such as prewarming patient prior theatre to 36°C were effective in management of intraoperative hypothermia.
The third phase involves the conducting of a follow up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. The implementation process is in place.
The results of this project including the positive changes in practice, the barriers and facilitators will be presented.


Biography:

Immigrated to Australia in 2001. Have been working in Royal Adelaide Hospital Burns Unit for 15 years including 9 years in Burns Operating Theatre. Currently undertaking evidence based clinical fellowship project with JBI. Graduate Diploma in Nursing Science (Perioperative Nursing)

A retrospective review of two years of intensive care admissions with a primary diagnosis of burns in a quaternary burns centre

Dr Juliette Mewton1, Dr  John  Gowardman1

1Royal Brisbane and Women’s Hospital , Herston , Australia

Abstract:

Introduction. Ninety-one patients were admitted to the Intensive Care Unit during 2015-2017. Admission characteristics, primary treatment, analgesia management and antimicrobial screening, infections and treatment were reviewed.

Methods. A retrospective chart review of ninety-one patients admitted to the Intensive Care Unit with a primary diagnosis of Burns.

Results. Of ninety-one admissions sixty-four were male and twenty-seven female. Median age at presentation was forty-three years (range fifteen- eighty-five). Cause of burn was deliberate self-harm in twenty-six patients (28.5%), accidental causes sixty-four (70%) and one forensic (1.5%). The mechanism of burn was electrocution four patients, accelerant thirty-three, MVA 2, House fire/blast fourteen, camp fire eight, or other causes five patients. Twenty-eight (31%) were direct admissions, fifty-nine transitioned through one facility, four via two centres and four from overseas.
The Total Body Surface Area range was eight-ninety-eight percent. The ICU length of stay was a median twenty-two days (range one – seventy-six days). Ten were palliated within twenty-four hours of admission seventeen patients died during admission (18.68%). On presentation only fifty-three (58%) were normothermic. Fifty-one had a lacticaemia (maximum 10.2 mmol/l). Forty-one had a haemoglobin below eighty or above one hundred and fifty-five grams per litre. Sixty- seven (73.6%) had more fluid resuscitation than their parkland calculation and that was despite forty-one patients having no pre-ICU fluids recorded. Forty required vasopressors and three patients required multiple agents. During their Intensive care stay fifty-seven had positive sputum microscopy, twenty-three positive blood and/or urine and twenty positive donor sites. Twelve had positive MRO screens.

Conclusions. There is still significant clinical variation in management and review of primary resuscitation. Inter-hospital transfer and geography can complicate the primary resuscitation. Early debridement is essential. A review of microbiology and multiple resistant organism screening may reduce costs and streamline care.


Biography:

Currently working as a Fellow in the Royal Brisbane and Womens Hospital, having had a significant interest in Burns management during my training in the UK as a Surgeon and in Australia as an Intensivist.

A simple method to colour balance digital photographs for remote assessment of tissue viability in acute burns

Mr Simon Chong1, Dr David Becker2

1Waikato Hospital, Hamilton, New Zealand, 2Waikato Hospital, Hamilton, New Zealand

Abstract:

Key to the practice of plastic surgery is the visual assessment of tissue perfusion via colour, most prominently when determining the depth of acute burns.

Digital imaging devices such as cell phones have provided a convenient means for remote assessment and referral of acute burns. However, most are optimised for use by inexpert photographers in non-medical applications. Accurate reproduction of colour is thus often compromised by environmental lighting, inconsistent use of flash illumination, and software bias. Digital devices will automatically optimise image parameters based upon the content of the image. White and black objects will be recognised and preferentially used to determine exposure and colour balance.

These variables often combine to produce a colour-inaccurate image with limited diagnostic utility and potential for misdiagnosis and liability.

We hypothesise that the routine placement of a white cotton swab within the photographic field of an acute burn will permit standardisation of colour balance across a variety of digital imaging devices.

Standardized photographs of a variety of burns will be taken with different devices. Six images will be taken: flash and non-flash with no swab present, flash and non-flash with a standard white cotton swab placed within the image framing, and flash and non-flash with a standard Pantone white colour swatch within the image.

The accuracy of the swab white balancing could be assessed with quantitative analysis utilizing Adobe Photoshop. Specifically, the variances in each Red Green Blue (RGB) colour channel could then be expressed as a percentage variance from the swatch-containing images.


Biography:

David is a Plastic Surgery registrar. Upon graduating from Otago University with an MBChB and Bachelor of Medical Laboratory Science in 2014 he worked in Dunedin as a house officer and surgical registrar; both in General Surgery and Plastic Surgery while completing a Postgraduate Diploma of Surgical Anatomy. Currently he is working at Waikato Hospital in Hamilton New Zealand.

Inpatient Burns Positioning Chart Review

Ms Nicole Alexander1

1Royal Children’s Hospital Melbourne, Parkville, Melbourne, Australia

Abstract:

Background:Burns positioning and splinting is important for oedema control, protecting surgical intervention, maintain joint range of motion and prevention of contractures (Kolmus et al. 2014). Positioning can be challenging due to surgical restrictions, medical stability and individual patient factors. In the paediatric setting, positioning is further complicated by children not possessing cognitive reasoning to aid compliance (Dewey, Richard, Parry, 2011). Leblebici et al. (2006) investigated the long term impacts of contracture on quality of life and found contractures impact physical function, bodily pain and vitality. An admission of a complex paediatric burn patient highlighted some position and splinting communication challenges in our tertiary paediatric hospital and a decision was made to review methods of communication.

Methods:Nursing staff were surveyed across the paediatric intensive care and surgical unit to explore barriers to positioning and suggestions to improve communication charts. After compiling the survey results, positioning charts are currently being reviewed and altered in response to feedback and commonly noted themes through our practice. The new positioning charts are hoped to be implemented for trial in June 2018. A follow up survey will be completed to assess the effectiveness of new positioning charts.

Outcomes:The new positioning chart will be discussed at the conference and we plan to have the results of the follow up survey to present at the conference.

Discussion:It is hoped that by collecting feedback directly from the staff involved in the interpretation of positioning charts that clarity and compliance will be improved.

References:

Dewey, WS, Richard, RL, Parry, IS. (2011) Positioning, Splinting and Contracture Management. Physical Medicine and Rehabilitation Clinics of North America, vol. 22, pp. 229-247.
Kolmus, A, West, S, Salway, J, Darton, A. 2014, ‘Splinting and Positioning’ in D.Edgar (ed) Burns and Trauma Rehabilitation: Allied Health Practice Guidelines,Lippincott Williams and Wilkins, Philadelphia, PA, pp. 151-174.
Leblebici, B et al. (2006). Quality of Life After Burn Injury: The Impact of Joint Contracture. Journal of Burn Care and Research, vol.27, pp. 864-868.


Biography:

Nicole is senior clinician for burns and plastics at The Royal Children’s Hospital in Melbourne.

Ventilator Associated Pneumonia in Burns Patients

Dr Jithesh Appukutty1, Dr  Cath Spoors1

1Mid Essex Hospital Nhs Trust, Broomfield, United Kingdom

Abstract:

Introduction:Ventilator associated pneumonia (VAP) contributes significantly to mortality in intensive care units; its incidence is often used as a key performance indicator. Diagnosing VAP is notoriously difficult; various scoring systems, exist with varied levels of sensitivity and specificity. Our aim was to assess VAP incidence in our Burns ICU, and compare scoring systems versus clinical diagnosis.

Methods:Burns ICU patients ventilated for at least 48 hours from December 2016 to September 2017 were included. Data were collected to assess compliance with ventilator care bundles, cuff pressure monitoring, post-pyloric feeding, and the criteria for VAP diagnosis from three scoring systems: HELICS¹, modified CIPS², CDC/VAP³, and CDC/VAC³. These were compared against clinical diagnoses of VAP.

Results:18 patients were ventilated beyond 48 hours, giving 288 ventilator days. The incidence of VAP by clinical diagnosis was seven per 1000 ventilator days, by HELICS at 17, and by modified CIPS at 83 per 1000 ventilator days respectively. There were no VAP episodes according to CDC criteria. Compliance with ventilator care bundles was high except sedation hold.

Discussion:The clinically diagnosed VAP rate was comparable to the available data for ventilated patients. There was significant overestimation of VAP episodes using the HELICS and modified CIPS scores. This is likely due to altered physiology (particularly temperature) and aspects of inhalational injury.

Conclusion:Diagnosis of VAP remains challenging. Scoring systems appear to overestimate VAP rates in burns patients.

Reference
1. Stewart NI, Cuthbertson BH. The problems diagnosing ventilator associated pneumonia. J Intensive Care Soc 2009; 10: 267–72
2. Centers for Disease Control and Prevention National Healthcare Safety Network. CDC-NHSN Ventilator-Associated Event (VAE), 2015. http://www.cdc.gov/nhsn/PDFs/pscManual/10- VAE_FINAL.pdf
3. Fartoukh M, Maître B, Honoré S, Cerf C, Zahar J, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 2003; 168: 173–9


Biography:

I am currently a Specialty Training Registrar Year 7 doing a fellowship in Burns and Plastic surgery anaesthesia as part of out of program training.  My interests include managing complex airways, intravenous anaesthesia

Perioperative Temperature Regulation of Patients in Burns Operating Theatre

Mrs Nithivadee Wattanaparada1, Mrs Rebecca Fox1, Dr. Helen Jeffrey1

1Burns Operating Theatre, Royal North Shore Hospital, North Ryde, Australia

Abstract:

Burns patients have difficulty maintaining their temperatures during surgical procedures so interventions which maintain the environmental temperature of the perioperative area are crucial to the success of surgical procedures. The purpose of this research is to compare the effectiveness of the warming mattress and the air-filled underbody warming blanket on maintaining patients’ temperatures during and post operating procedures. This has been done by collecting temperature data of burns patients who underwent procedures during which it was difficult to cover the body area. Upon the examination of these results, it was clear that the warming mattress was more effective than the underbody blanket at maintaining patients’ temperatures, however, its use is not suitable for cases that require disinfecting solutions that can result in degradation of the mattress.


Biography:

Nithivadee is an anaesthetic nurse who has been a member of the Burns Operating Theatre team for over 10 years.  She has done research on Self-Care Education for patients with tubercolosis and AIDS and was a member of the Ministry of Public Health of Thailand specialising in Communications and Disease Control Association.

Physiological characteristics and recovery pattern of dysphagia and dysphonia following inhalation injury: a 10 year review

Dr Nicola Clayton1,2,3,4, Dr Rosalba Cross3, Dr Mark Kol3, Prof Peter Maitz1,5

1Burns Unit, Concord Repatriation General Hospital, Concord, Australia, 2Speech Pathology Department, Concord Repatriation General Hospital, Concord , Australia, 3Intensive Care Unit, Concord Repatriation General Hospital, Concord, Australia, 4School of Health & Rehabilitation Sciences, University of Queensland, St Lucia, Brisbane, Australia, 5University of Sydney, Camperdown, Australia

Abstract:

Background: The impact of inhalation burn injury on swallowing and laryngeal function is not well understood. Limited evidence suggests that inhalation injury to the upper aerodigestive tract may be associated with increased risk for dysphagia and dysphonia however the specific features of laryngeal pathology, recovery pattern and non-surgical treatment options has not been documented.

Purpose: To describe the physiological characteristics and pattern of recovery of swallowing and laryngeal pathology following inhalation thermal burn injury.

Methods: All patients admitted with thermal burn injury, including a suspected inhalation component, between 2008 and 2017 inclusive were reviewed for inclusion within the study. Those diagnosed with dysphagia and laryngeal pathology formed the final cohort. Demographic, burn and critical care data were collected in addition to swallowing, voice and laryngeal outcome measures from the point of admission through to discharge.

Results & Conclusions: Preliminary data suggests that while these patients often recover swallowing ability during their acute care admission, longer term laryngeal pathology affecting airway and vocal function may be experienced. Key features of dysphagia include both motor and sensory aspects to swallowing dysfunction with onset evident early in the acute admission. Laryngeal pathology however, is an evolving process, potentially compounded by medical and demographic factors, with late evidence of scar tissue and contracture. Specific physiological characteristics and treatment regimes are explored in this highly challenging population, with early identification of pathology associated with better patient outcomes.


Biography:

Nicola is a clinical specialist speech pathologist at Concord Repatriation General Hospital. She is recognised nationally and internationally for her clinical expertise and research in the assessment and treatment of complex swallowing disorders following severe burn injury and completed her PhD in this area.

Retrospective review of airway involvement in SJS/ TENS

Dr Harmeet Bhullar1, Dr  Ar Kar Aung1,2, Dr Heather Cleland1,2, Dr  Josh Ihle1, Ms Linda  Graudins1, Dr Bing Teh1

1Alfred Health, Melbourne, Australia, 2Monash University, School of Medicine, Clayton, Australia

Abstract:

Background:Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TENs) are life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. There are currently no large studies to support the routine use of functional nasendoscopy (FNE) and the predictive factors for intubation in these patients.

Objectives:To determine key indicators for intubation in the SJS/TENS patient cohort.
To determine FNE findings which indicate need for early intubation.

Methods: A retrospective chart review of 37 patients with biopsy proven SJS/TENS admitted at Alfred Health from 2010 to 2017.

Results:Seventeen (46%) patients underwent intubation while 3 (8%) had tracheostomies. Intubated patients were more likely to be diagnosed with TENS (94%) vs non-intubated (60%) patients (p <0.05). A SCORe of TEN (SCORTEN) of 2 on day 3 was more likely in the intubated (IQR 2-3.5) vs non-intubated (IQR 1-2) group (p<0.05). An increase in TBSA (%) day 1-3 was higher in the intubated [10 (IQR 0-22.5)] vs non-intubated [0 (IQR 0-4.5)] (p<0.05) group. Patients in our cohort were intubated to facilitate theatre and dressing management (56%), respiratory distress (33%) and drop in Glasgow Coma Scale (13%). FNE was performed on 29 patients; 14 were intubated. FNE findings were not predictive of intubation in our cohort.

Conclusion: Nearly half of all patients with SJS/ TENS require airway intervention. Diagnosis of TENS, SCORTEN of 2 (day 3) and progression of TBSA of at least 10% (day 1 to 3) are associated with the need for intubation. FNE should be prioritised for patients with high risk factors.


Abstract:

Dr Harmeet Bhullar holds a Doctor of Medicine from the University of Melbourne and a Bachelor of Pharmacy from Monash University. She is currently a surgical resident at Alfred Health. She has travelled extensively, and is an avid reader. She is keen to pursue a career in surgery.

The cost of Self Immolation – 20 years of data from RBWH

Dr Mikaela Seymour1, Dr  Andrew  Maurice1, Dr Jason  Brown1

1Royal Brisbane and Womens Hospital, Stuart Pegg Burns Centre, Brisbane, Australia

Abstract:

Self immolations are usually very large burns, difficult to treat, and use a large portion of health resources. The patients generally have psychiatric co-morbidities which complicate optimal care and follow up. The severe nature of these burns typically means they are over-represented in the workload of burns staff, and in the budget of Burns units. This poster will examine the cost of self immolation in a large Tertiary Burns referral centre, demonstrating the large proportionate spending on Self immolation compared to accidental burns.

The burns unit at the Royal Brisbane and Women’s Hospital in total, admitted or performed day surgery on 5815 patients with mean 10% TBSA burns during the last 20 years. Self immolations constituted 125 (2%) of these admissions, with a mean Total Body Surface Area Burn of 45%, constituting 11% of all TBSA treated over this time period.

Analysis of all Intensive Care Unit admissions for burns patients was performed and 24% of the ICU bed days were found to be Self immolations. The average cost of a day in ICU was between AUD $2670- 9852.

Although the care of Self immolations usually involves long admissions (and re-admissions), frequent outpatients visits, refractory mental illness, significant allied health input and resources, to estimate the entirety of health expenditure on self immolation is extremely difficult.

This poster examines the cost to the health service of the index admission per ICU and ward bed day required for Self immolators, with a break down comparison per Total Body Surface Area to accidental burns. It concludes that a large portion of health resources is being used on a small portion of admissions, challenging the audience ethically to consider their current treatment of Self immolations and foster a greater understanding of this burns populations impact on our health service.


Biography:

Dr Mikaela Seymour is a General Surgery PHO at the Sunshine Coast University Hospital. She has previously worked at the Royal Brisbane and Womens Stuart Pegg Burns Centre.

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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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