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.

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.

Improving health literacy and shared decision making between clinicians and Aboriginal and Torres Strait Islander paediatric burn patients.

Ms Hayley Williams1,2, Dr Bronwyn Griffin1,3, Dr Kate Hunter4, Professor Kathleen Clapham5, Professor Rebecca Ivers4, Professor  Roy Kimble1,2

1Centre for Children’s Burns and Trauma Research, Lady Cilento Children’s Hospital, Brisbane, Australia, 2Faculty of Medicine, University of Queensland, Brisbane, Australia, 3School of Nursing, Queensland University of Technology, Brisbane, Australia, 4The George Institute of Global Health, University of New South Wales, Sydney, Australia, 5University of Wollongong, Wollongong, Australia

Abstract:

Background: Paediatric burns care can be overwhelming and impact on the patient and family’s ability to acquire and retain important information. Caregivers of Aboriginal and Torres Strait Islander children with burn injuries have indicated strong desires for more detailed information and engagement in decisions regarding their child’s treatment. Burns clinicians have a vital role to ensure patients and families understand their treatment and are able to participant in knowledge sharing and decision making. However, little research has explored burn clinician’s understanding of their role and ability to develop health literacy among patients and families.

Methods: Burn clinicians providing treatment to Aboriginal and Torres Strait Islander children will be interviewed directly following the children’s appointments. ‘Thinking aloud’ sessions involving unfiltered verbal sharing of thoughts, followed by five-itemed exit interviews will be used to explore burn clinician’s information sharing and perceptions of patient and families understanding. Grounded theory approaches will be used to analyse burn clinicians understanding of the development of health literacy skills.

Results: Data collection and analysis has commenced, and emerging categories will be presented.

Discussion: Burn clinicians have a responsibility to provide patients and families with clear, comprehensive, and culturally appropriate health information. However, few resources and supports are available to aid them to do this effectively. These results will inform the next phase of the study in which burn clinicians will be invited to discuss solutions that will inform the development of resources/interventions to support them in their role of developing health literacy among their patients and families.


Biography:

Hayley Williams is an Aboriginal researcher with family ties in Tingha and Inverell in north-eastern NSW. Hayley has a Bachelor of Social Science and Postgraduate Diploma in Psychology, and is currently completing a Doctor of Philosophy exploring the emotional impact of burn injuries on Aboriginal and Torres Strait Islander children and the cultural safety of burns care. Hayley is passionate about improving the health and wellbeing of Aboriginal and Torres Strait Islander people, and has a particular interest in emotional traumas and the resilience of Aboriginal and Torres Strait Islander children and adolescents.

Initial clinical experience using Matriderm to treat a paediatric full thickness facial burn: a nursing perspective

Deborah A E Maze1, Gisela A Olson2

1The Burns Unit & the Children’s Hospital at Westmead Burns Research Institute, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW 2145 deborah.maze@health.nsw.gov.au

2The Burns Unit & the Children’s Hospital at Westmead Burns Research Institute, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW 2145 gisela.olson@health.nsw.gov.au

Abstract

The management of full thickness facial burns can be challenging and complex. In 2017, our Burns Unit treated a 2 year old female who sustained a 60% TBSA full thickness flame burn injury involving the entire face.

Successful regeneration of dermal tissue is important in the restoration of normal functionality and aesthetic appearance. Advancements in the development of skin substitutes aim to provide improved elasticity, flexibility, stability and strength of the reconstructed skin whilst reducing wound contraction and improving scar appearance.

Surgical management of full thickness facial burns in our institution has previously involved early tangential excision (+/- temporary application of cadaveric skin) and split thickness sheet grafting.

This case study will demonstrate the use of Matriderm, a collagen-elastin matrix dermal substitute, applied in a one-stage surgical procedure in combination with a split thickness skin graft to reconstruct the full thickness facial burn wound, a first for the treatment of a paediatric full thickness facial burn in Australia.

Discussion will include initial wound management, the application process for Matriderm, challenges around wound management post skin grafting and complications experienced. An early scar management regime was initiated and included use of a transparent face orthosis and custom made compression garment. Initial skin graft results will be included along with the child’s outcome at 10 months post burn injury.

Matriderm has proven to be a successful dermal substitute in this case. Ongoing follow up will be required to determine the long term outcome of skin quality, pliability and scar appearance.

References

  1. Atherton D, Tang R, Jones I, Jawad M. Early excision and application of Matriderm with simultaneous autologous skin grafting in facial burns. Plastic & Reconstructive Surgery, 2010
  2. Demircan M, Cicek T, Yetis M. Preliminary results in single step wound closure procedure of full thickness facial burns in children by using the collagen-elastin matrix and review of paediatric facial burns. Burns, 2015
  3. Min J, Yun I, Lew D, Roh T, Lee W. The use of Matriderm and autologous skin graft in the treatment of full thickness skin defects. Archives of Plastic Surgery, 2014
  4. Haslik W, Kamolz L, Nathschlager G, Andel H, Meissl G, Frey M. First experiences with the collagen elastin matrix Matriderm as a dermal substitute in severe burn injuries of the hand. Burns 2006
  5. Shevchenko R, James S, James E. A review of tissue-engineered skin bioconstructs available for skin reconstruction. Journal of The Royal Society Interface 2009
  6. Suwelack A, MedSkin Solutions, Matriderm product information 2014

 

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

Implementing a Nurse Practitioner led burn ambulatory care clinic. Review of the effectivieness of the role 4 years post implementation.

Mr Peter Campbell1

1Royal North Shore Hospital, Concord, Australia

Abstract:

The role of a Nurse Practitioner in the burns ambulatory care environment is a relatively new concept and has required a change in Care Modelling. This paper aims to describe the impact a Nurse Practitioner can have in the burns ambulatory care environment, and the support required from both Nursing & Medicine to enable the role to be implemented and supported. How a Nurse Practitioner can aide in enhancing Multidisciplinary and Interdisciplinary involvement in patient care will be discussed. An analysis of statistics for the past 4 years will be discussed to demonstrate the impact a Nurse Practitioner can have on patient management.

The 4 pillars of Nurse Practitioner practice will be examined to demonstrate what differences in outpatient care can be achieved.


Biography:

Worked in Burns & Plastics for 29 years. Has been a member of ANZBA for 23 years and regularly helps coordinate EMSB courses. Has worked in several roles in burns including Management and clinician positions, he has an OAM for his contribution to burn education and burn development.

Can lime juice cause burns? A case series of paediatric phytophotodermatitis.

Dr Dinuksha De Silva1, Dr Aruna Wijewardena1

1Royal North Shore Hospital, Sydney, Australia

Abstract:

We present an unusual series of ‘lime burns’: three cases of bilateral hand blistering and erythema were recently referred to our unit at Royal North Shore Hospital. A seven-year-old girl presented in March 2016 after juicing 200 limes, and a five-year-old girl and her seven-year-old brother presented in March 2018 after picking and juicing limes in Byron Bay. The five-year-old girl experienced progression to a large fluid-filled bulla overlying the dorsum of the right hand and three metacarpophalangeal joints. All three children were exposed to sunlight following contact with limes. The injuries were equivalent to superficial dermal burns – was lime juice the culprit?

We conducted a literature review on phototoxic lime-induced dermatitis. Phytophotodermatitis is a term introduced by Klaber in 1942 to describe the reaction of skin to sunlight after contact with furocoumarin-containing plant species. The plants commonly implicated are limes and oranges (Rutaceae family); parsley and celery (Umbilliferae); and figs (Moraceae) (Wagner 2002). Skin reaction occurs after contact with the photosensitising agent and exposure to ultraviolet A radiation.

We report findings from our cases in the context of this review. Progression of the cases was largely consistent with the literature: erythema within 24 hours of lime contact, vesiculation at approximately 72 hours and exfoliation at 10-14 days. Subsequent hyperpigmentation may persist for 6-12 months, and fortunately scarring is rare in children (Wagner 2002). Specialised topical treatment may be required, and cases involving >30% body surface area should be managed in a burns unit (Raam et al 2016).

References
1. Klaber RE 1942, ‘Phytophotodermatitis’, Br J Dermatol, vol. 54, pp. 193–211.
2. Raam, R, CeClerck, B, Jhun, P & Herbert, M 2016, ‘Phytophotodermatitis: The Other “Lime” Disease’, Ann Emerg Med, vol. 67, pp. 554-556.
3. Wagner, AM, Wu, JJ, Hansen, RC, Nigg, HN & Beiere, RC 2002, ‘Bullous phytophotodermatitis associated with high natural concentrations of furanocoumarins in limes’, Am J Contact Dermat, vol. 13, no. 1, pp. 10–4.


Biography:

Dinuksha is a surgical SRMO in the Burns and Plastic Surgery Department at Royal North Shore Hospital in Sydney.

Preventing web space contractures in hand burns

Dr Dinuksha De Silva1, Dr Aruna Wijewardena1

1Royal North Shore Hospital, Sydney, Australia

Abstract:

Hand burns are a common injury – they are involved in 42-80% of all burn injuries (van der Vlies et al. 2017, Kamolz et al. 2008), and can have a devastating impact on function and quality of life. A major contributor to this impact is web space scar contracture. It is the most frequent indication for reconstructive surgery after a hand burn (van der Vlies 2017), and a number of techniques have been described in the literature for web space contracture release. The mainstays for preventing this are supervised passive motion protocols and compressive garments (Fufa, Chuang & Yang 2014). However, can we optimise acute surgical management to help prevent web space contracture?

Here we present our experience at a tertiary burns centre in Sydney using a protocol initially described by Dr Chandini Perera (Burns and Plastic Surgeon, Sri Lanka). This technique involves grafting dorsal hand and finger burns without grafting the web spaces. We avoid grafting interdigital skin, as it contains a continuation of glabrous skin similar to that of the palm. A period of 21 days from injury is observed without operating on web space skin.

This surgical case series of hand burns outlines functional and cosmetic outcomes at follow up. Following the aforementioned protocol, we have been able to obviate the need for post-burn reconstructive surgery for web space contracture.

References
1. Fufa, DT, Chuang, SS & Yang JY 2014, ‘Postburn Contractures of the Hand’, Journal of Hand Surgery, vol. 39, no. 9, pp. 1869-1876.
2. Kamolz, LP, Kitzinger, HB, Karle, B & Manfred, F 2008, ‘The treatment of hand burns’, Burns, vol. 35, pp. 327-337.
3. van der Vlies, CH, de Waard, S, Hop, J, Nieuwenhuis, MK, Middelkoop, E, van Baar, ME, van Zuijlen & PPM 2017, ‘Indications and Predictors for Reconstructive Surgery After Hand Burns’, J Hand Surg Am, vol. 42, no. 5, pp. 351-358.


Biography:

Dinuksha is a surgical SRMO in the Burns and Plastics Department at Royal North Shore Hospital in Sydney.

Epidemiology of burns patients admitted to the State-wide Adults Burns Service in Queensland: A 10-year Review

Ms Jacelle Warren1, Dr Cate Cameron1, Dr Michael Muller2

1Jamieson Trauma Institute, Herston, Australia, 2Royal Brisbane & Women’s Hospital Burns Unit, Herston, Australia

Abstract:

Introduction:The last epidemiological review of adult burn injuries in Queensland was 15 years ago. It is important to have updated data for this cohort so effective burns services can be maintained, and a base for assessing the impact of new treatments/initiatives (e.g. the introduction of the Skin Culture Centre, introduction of the National Injury Insurance Scheme Queensland (NIISQ)) can be established.

Aims: To describe the incidence, demographic, injury, acute treatment and acute outcomes of adult burn patients admitted to the RBWH Burns Unit.

Methods: A secondary analysis of data is being undertaken on adult burns patients admitted for acute treatment to the RBWH Burns Unit between 01 January 2008 and 31 December 2017.

Results: Between 2008 and 2017, there were 3,950 acute admissions to the RBWH Burns Unit. Males (Median age = 36yrs, IQR = 24 – 51yrs) accounted for 72% of acute admissions. Initial analyses suggest that flame-related burns were common, most burns occurred within a dwelling/yard, and 20% either involved motor vehicle or work-related accidents. As expected, there was frequent use of surgical interventions, ICU admissions and length of acute hospital stays (LOS) longer than 1 week. There were 69 (1.7%) deaths. Trend analyses over the 10 years in relation to demographic, injury, acute treatment and outcomes will be presented.

Conclusion: These finding are relevant to clinicians and trauma care services within Queensland, as well as to external key stakeholders such as WorkCover and Insurance Regulators, in light of the recently introduced NIISQ.


Biography:

Ms Warren is a Biostatistician in the Jamieson Trauma Institute and has previously spent ten years working in data management, data analysis and reporting of injury data collected by the Queensland Trauma Registry (QTR).

Ms Warren has extensive experience with statistical analysis of large injury datasets, both cross-sectional and longitudinal, and has a particular interest in the physical and psychological recovery of injured people.

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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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