A review of The National Burn Centre referral patterns

Nicholas Solanki1, Sarah Shugg1, Tess Brian1, Richard Wong She1

1The National Burn Centre, Middlemore Hospital, Otahuhu, New Zealand


Introduction: The National Burn Centre (TNBC) at Middlemore Hospital in Auckland first opened in 2006.  Its role is to provide care for the most severely burn-injured patients from around New Zealand, receiving referrals from the regional burns units. In addition, TNBC also treats severe burn patients transferred from Tahiti according to a government agreement.

Methods: A review of the first 10 years of TNBC from 2006 to 2016 was performed to assess referral patterns using data gathered from the burn database at Middlemore Hospital. The primary focus was on acute patients that were transferred from other regions or who met TNBC referral criteria.

Results: Over this period there were 3398 burn admissions to Middlemore Hospital. Of these 361 fulfilled TNBC referral criteria.

Conclusions: 56% of patients were transferred from the ‘local’ region (Auckland and Waikato) while fewer patients were transferred from the units located farther away (Hutt and Christchurch). Just over half of all patients had an injury less than the referral criteria of 30% TBSA, indicating they had smaller but more complex burn injuries. The median age of patients from Auckland was significantly higher (P=0.001, Students T-test). The median length of stay was slightly higher in the patients from Auckland and Tahiti, as patients referred from other regional units were transferred back once their acute surgery was complete.


Sarah Shugg is a Plastic and Reconstructive Surgery registrar in NZ currently working as part of the burn team at The National Burn Centre at Middlemore Hospital.”

Post-discharge Analgesia in Burns Patients

Dr Rachel Khoo1, Dr Annette Camer-Pesci1, Dr Helen Douglas1, Prof Fiona Wood1, Dr Suzanne Rea1

1State Adult Burns Unit, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch WA 6150


Background:Burn wound pain management is challenging and complex. Traditionally, the use of opioid analgesia has been the mainstay approach. However, the use of such analgesia is not without side-effects and risks. A nationwide restriction on over-the-counter purchase of codeine products was recently introduced due to widespread concerns regarding risks of addiction and abuse. In contrast, the use of non-opioid analgesia, physiotherapy, oedema control, and non-pharmacological techniques have increased amongst practices. Most of our smaller injuries are discharged on Paracetamol and Celecoxib; with the use of Pregabalin and Tramadol considered on a case-by-case basis. We wished to discover what analgesia our inpatients with smaller burn injuries (<10% TBSA) were taking post-discharge.

Methods:Looking at a cohort of inpatients with burn injuries (<10% TBSA), a 4-week prospective community-based telephone survey of discharged inpatients was carried out. Questions regarding analgesia requirements, pain scores and adequacy of pain control in the acute period were assessed on discharge, at 48hrs, one week, and at six weeks post-discharge.

Discussion: Adequate pain control in a burn patient is paramount for their journey to recovery. The increasing problems seen with painkiller addiction, has led us to question whether we are over or under prescribing such analgesia and what our population requirement is in the smaller burn injury. In assessing our practice, we aim to discover the level of adequate analgesia to control patient pain, allow therapy, and a return to activity vital to their rehabilitation.


Rachel is currently a service registrar at Royal Perth Hospital. Her interests lie in the pathophysiology of wound healing, anatomy, and rock climbing.

‘Kenacomb Ointment’ for hypergranulation tissue in burns: a review of efficacy and adverse effects

Dr Nicholas Tang1

1Royal Melbourne Hospital, 300 Grattan St, Australia


Background: Hypergranulation tissue has been described in the literature as a deterrent to complete wound healing following skin-grafting to burns1. ‘Kenacomb Ointment’, a combination of triamcinolone acetonide, neomycin sulfate, gramicidin and nystatin, is often used following skin-grafting for management of hypergranulation tissue. This likely stems from the hypothesized effect of topical steroids on granulation tissue as well as its anti-microbial properties. Its use has been widely accepted in the treatment of burns, however evidence regarding its efficacy and side effects is lacking.

Methods: We performed a literature search of Medline, Pubmed, Embaseand the Google Scholar library for ‘Kenacomb’ with granulation tissue and burns. Clinical studies on the topical use of these medications on wounds were included.

Discussion: There is much lacking in current literature, with no articles describing the use of ‘kenacomb’ in burns management and only a handful of case reports or series’ describing the use of topical steroids in the management of hypergranulation tissue. At the same time there are a number of case reports and series’ describing the severe side effects of ototoxicity and nephrotoxicity following topical administration of Neomycin to burn wounds.

Conclusion: There is a paucity of clinical evidence in the literature that advocates for the use of topical ‘Kenacomb’ on burns wounds and, given its potential side effect profile, further research is required to assess its safety for ongoing clinical use.

1. Jewell L, Guerrero R, Quesada AR, Chan LS, Garner WL. Rate of healing in skin-grafted burn wounds. Plast Reconstr Surg. 2007 Aug;120(2):451-6.


Nicholas Tang is currently a HMO at the Royal Melbourne Hospital

Scar Hyperpigmentation in Pregnancy

Ms Nicole Wong1, Dr Helen Douglas2, Dr Anna Goodwin-Walters2

1The University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand, 2State Adult Burns Unit, Murdoch, Australia


Background:It is well accepted that a variety of pigmentation changes occur in over 90% of pregnant women. Regions that are hyper-pigmented in the non-pregnant state become further pigmented during pregnancy. Little is known about how pregnancy affects scar pigmentation and cosmesis following burn injury.

Case and Literature Review:We present the case of a 38-year-old Afghani woman in her first trimester of pregnancy who sustained a scald burn to her left calf (1.5% TBSA) and left wrist (<1% TBSA). These wounds were managed conservatively and healed within 15 days. At her 3-month review there was a flat but significantly hyper-pigmented area over the healed wound despite timely healing and strict sun avoidance. A thorough search of the literature did not reveal any similar reported cases and few articles reported on scar outcomes of the pregnant burn patient. Full details of the case and a review of the current evidence regarding burns, wound healing and scarring in the pregnant patient is presented.

Discussion:The relative immunosuppression of pregnancy has led some researchers to postulate that scar formation in this group may be favourable, whilst others report a negative impact of pregnancy hormones on wound healing. However, it is possible that raised levels of oestrogen and progesterone (known melanocytic stimulators) in the gravid patient contribute to hyperpigmentation of wounds, even in those healed within a timely fashion. Whether this pigmentation will resolve or improve post-partum and on the cessation of breast-feeding is another question we are interested to answer.


Nicole Wong is a final year medical student from The University of Auckland, New Zealand. Nicole undertook her selective clinical placement at the State Adult Burns Unit, Fiona Stanley Hospital, WA.

Current Burn Scar Management Practices for the Face and Neck

Mr Michael Andreas Serghiou1

1Bio Med Sciences, inc., Allentown, United States


Introduction: The physical challenges of caring for the injured face and neck require a high degree of skill that is often missing in burn training curriculums. New rehabilitation technologies have emerged and should be incorporated into scar management training programs. A comprehensive rehabilitation training program for the face and neck has been developed and tested for its efficacy.

Methods: A review of the burn rehabilitation training literature was performed. We found no specific training programs that address the face and neck of the burn survivor. The 2-day program includes a 4-hour didactic session and an 8-hour “hands on” experience. Pre/post training data was collected from 162 Occupational and Physical therapists at 11 facilities in the US to measure the success of the program.

Results: Therapists (97%) were extremely satisfied with the course indicating that they will apply the knowledge gained into their practice (95%). Most therapists (88%) never fabricated all the appliances demonstrated in the course. Perhaps our most important finding is that therapists did not previously consider a comprehensive approach to treating the face and neck (91%). Therapists (98%) indicated that the didactic portion of the course followed by the “hands on” experience was well fitting to immediately apply learned principles into practice.

Discussion: We have identified that focused burn rehabilitation training courses are rare and that therapists welcome new educational opportunities via meaningful “hands on” training courses, that can directly impact their practice. Training courses for burn therapists must be comprehensive, incorporate updated modalities and be evidence based.


Michael is an Occupational Therapist practicing in the area of Burn Rehabilitation for 28 years. Michael has published numerous burn rehabilitation manuscripts and authored chapters in the

journals of Burn Care and Research and Burns and in various burn care related text books. He has served on the Board of Trustees of the American Burn Association (ABA) and is currently

serving on the Board of the International Society for Burn Injuries (ISBI). As a clinician, Michael has received the ABA Barbara Knothe Outstanding Therapist Clinician Award, The ISBI Andre

Zagame Therapist Prize and the Physicians for Peace Medical Diplomat Award for his outstanding service in the international outreach area.


Burn injury in the morbidly obese: changes and challenges

Dr Kieran Robinson1, Dr Helen Douglas1, Dr Anna Goodwin-Walters1

1State Adult Burns Unit, Fiona Stanley Hospital, Perth, Australia


Background:The management of burns in the morbidly obese patient poses complex challenges for the burns team. This is becoming increasingly relevant as the prevalence of obesity continues to rise in Australia and the developed world. The optimal management of these patients is more difficult at all stages in their care; from burn assessment and resuscitation, ICU management and surgery through to recovery and rehabilitation.

Methods:We conducted a review of the literature for articles concerning burn injury in obese patients and report the results along with the presentation of two cases managed at the State Adult Burns Unit in Western Australia, where obesity presented specific management issues for us as a service.

Results:The results of the literature search revealed relatively few studies regarding the experience and management of burn injuries in the morbidly obese.

Discussion:Obesity is increasing in our population at an alarming rate and is a huge public health issue for Australia. Awareness and anticipation of some of the specific challenges which exist when managing morbidly obese patients with burn injuries is useful to any burns team. Specific pitfalls and problems encountered and measures taken to rectify them are presented.


RMO in the State Adult Burns Unit at Fiona Stanley Hospital, Western Australia

Representations of Facial Scars in Film

Dr Isobel Yeap1, Dr Kersandra Begley1, Dr  Aruna Wijewardana1, Dr John Vandervord1

1Royal North Shore Hospital, Sydney, Australia


Background: The villain with the scarred or disfigured face is a widespread trope in contemporary film. Often, facial scars serve as a visual metaphor for the hurt or damage that a character has been through, as well as a defining characteristic that marks the character as the villain.

Aim: To systematically collect and analyse data on the representation of facial scars in the most commonly watched films. The null hypothesis is that the representation of facial scars in film will be a negative one.

Method: Data were collected from the 100 worldwide highest grossing films including the number of characters with facial scars, their sex, whether they were heroes, villains or morally ambiguous characters and whether or not their scars were covered.

Results: The findings indicate that 50% (27/54) of the films included a character with facial scars. These 27 films included 44 characters with facial scars. The majority of characters with facial scars were male (93%; 41/44) and villains (59%; 26/44). We then classified the characters’ scars as either obvious or subtle and found that villains were much more likely to have obvious scars (58%; 15/26) compared with heroes (29%; 4/14).

Conclusion: Rather than being portrayed as a benign variation in human appearance, or even as a metaphor for resilience, facial scars are most often deployed as an insidious visual reminder that the character is damaged or bad. This likely contributes to the negative stigma faced by patients who have suffered facial burns that have caused conspicuous scarring.


Isobel is a resident medical officer who has worked with the Severe Burns Unit and Plastic Surgery Department at Royal North Shore Hospital. Prior to studying medicine, she completed her Bachelor (Honours) in Economics. She also works as a film writer for online for 4:3 Film.

Predictors of Outcomes in Patients with Facial Burns: A Retrospective Chart Review

Dr Isobel Yeap1, Dr Aruna Wijewardana1, Anne Darton1, Dr John Vandervord1

1Royal North Shore Hospital, St Leonards, Australia


Background: As well as allowing one to see, hear, speak, eat and breathe, the face is central to one’s ability to communicate expression and emotion. Consequently, burns to the face are especially debilitating and are associated with poorer functional and psychological outcomes.

Method: We conducted a retrospective chart review on 726 patients with facial burns who presented to Royal North Shore Hospital’s Severe Burns Unit during a ten-year period (2008 to 2017). Data were analysed using SPSS®. Multiple linear regression and binary logistic regression models were used.

Results: 82% of patients were male and 64% of patients had < 10% total body surface area (TBSA) burned. Amongst patients with TBSA > 10%, those with non-accidental burns were at a 5.27 times increased chance of dying during initial admission. The presence of inhalational injury was found to have no effect on mortality, once TBSA % burned and facial burn depth was accounted for. Amongst patients with TBSA < 10%, the presence of inhalational injury increased length of stay by 4.70 days on average, while those with non-accidental burns had an increased length of stay of 4.83 days.

Conclusions: Special care should be taken when treating patients whose burns are due to non-accidental causes, since they have a much higher chance of dying during initial admission. While the presence of inhalational injury increases a patient’s length of stay, it does not influence mortality, suggesting that our current treatment approach to inhalational injury may be highly successful.


Isobel is a resident medical officer who has worked with the Severe Burns Unit and Plastic Surgery Department at Royal North Shore Hospital. Prior to studying medicine, she completed her Bachelor (Honours) in Economics.

Chondritis in the burned ear: a narrative review

Dr Isobel Yeap1, Dr Aruna Wijewardana1, Dr John Vandervord1

1Royal North Shore Hospital, St Leonards, Australia


The burned ear represents a unique challenge for several reasons. One of the reasons is that the ear has little soft tissue coverage, such that deeper burns result in damage to cartilage. Related to this, exposed cartilage is vulnerable to infection, which can lead to further damage to the ear structure. A deformed ear, while not life threatening, can lead to problems with hearing, as well as long-term psychological problems. Before the topical application of antibiotics became commonplace practice, chondritis in the burned ear was a common and well-recognised complication. Since the 1960s, however, incidence rates have been decreasing and, as per some estimates, are now approaching zero.

In this study, a narrative review on chondritis in the burned ear was conducted. First, we describe the organisms most commonly implicated. Second, we discuss the clinical manifestations and approach to the diagnosis of chondritis. Finally, we take a historical approach and look at the range of management strategies for chondritis that have been described in the literature. We find that the declining incidence of chondritis is attributable to a paradigm shift whereby the emphasis is placed on early coverage of cartilage, routine use of topical antibiotics and immaculate pressure care.


Isobel is a resident medical officer who has worked with the Severe Burns Unit and Plastic Surgery Department at Royal North Shore Hospital. Prior to studying medicine, she completed her Bachelor (Honours) in Economics.

Burns from Plaster Backslabs: Is Current Practice Safe?

Dr Tam Quinn1, Dr Hein Maung1

1Eastern Health, Melbourne, Australia


Introduction:Plaster of Paris can reach temperatures of up to 82.2°C and cause thermal injuries. Factors contributing to high plaster temperatures include plaster thickness, temperature of the dipping water, the use and thickness of padding between skin and plaster, and ventilation of the plaster as it sets
Method:Using a simulated limb, we tested the effects of plaster thickness, thickness of padding, decreased ventilation and water temperature on the temperature of the plaster. We recorded the temperature of the plaster at 5 minutely intervals to find the peak temperature.
Thicker plasters produced higher temperatures than thinner plasters as did a higher temperature of the dipping water. The number of layers of padding did not produce significant differences in the temperature of the plaster. Covering the plaster with blankets caused a small increase in the temperature of the plaster compared to no blankets. The peak temperature at dipping water temperatures of 20°C and 40°C was recorded at 20 minutes, and at 60°C was found to peak at 15 minutes.
We were unable to produce temperatures greater than 52°C for periods greater than 5 minutes which is what has previously been reported as a condition by which burns can occur. However, our results corresponded with previous research in that thicker plasters and higher dipping water temperatures produced higher temperatures. To ensure patient safety, our recommendations are for the minimum thickness of plaster required to be used and dipped in water no greater than 20°C.


Tam is a senior trainee in Plastic and Reconstructive Surgery with a long interest in burns following time spent working with the team at the Victorian Adult Burns Service



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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