Assessment and Management of Hot Springs Burns in New Zealand

Dr Ming-Chi  Wang1, Dr Theresa  Magoye1, Ms Deirdre Seoighe1

1Waikato Hospital, Hamilton , New Zealand


Aim: New Zealand is a geothermically active country with numerous easily-accessible hot springs. Yet there is paucity of data and of previous research to guide the assessment and management of burns injury sustained in hot springs. We aimed to review the current literature; and report the presentation of hot spring burns in a major regional burns referral centre.

Method: A retrospective review of medical records gathered from Waikato Hospital, a regional burns centre in New Zealand was performed to examine the pattern of injuries sustained, rate of use of antimicrobial agents and wound infection rates in hot-spring related burns. A literature search was also performed to look for evidence to support early prescription of antibiotics and correlate the rate of infection in hot spring burns.

Results: Medline and Google Scholar search combining the following terms: “burns” and “hot springs” did not return any result pertaining to the current practice in managing hot-spring burns. On review of our database we found inconsistent use of antibiotics and less than thorough microbial investigations performed in the early stages of burns management.

Conclusions: We present a retrospective study of the assessment and management of hot springs burns in a major regional burns centre in New Zealand. To our knowledge, no previous study has singled out this mechanism of burns to examine its characteristics, and there is no evidence to support the empirical use of antibiotics in its initial management.


Surgical registrar at Waikato Hospital

Brothers Who Burn: Two Paediatric Case Reports of para- Phenylenediamine (PPD) Sensitisation to Black Henna.

Dr Rachael  Stokes1, Dr Camille Wu1, Dr  Susan Adams1

1Sydney Children’s Hospital, Randwick, Australia


The addition of para-phenylenediamine (PPD) to red henna to create a cosmetically pleasing temporary black henna tattoo (TBHT) is well established in tourist industries worldwide. This molecular compound can induce severe skin sensitization.  Clinical manifestations of the type IV delayed hypersensitivity reaction vary from erythema, to allergic contact dermatitis (ACD) – most commonly, to chemical burns. Type I hypersensitivity reactions (urticaria, angioedema, or anaphylaxis) with potentially lethal reactions have also been documented, although less frequently.  This report describes two siblings presenting with suspected PPD sensitisation leading to chemical burns, and summarises the literature on this clinical problem. Case Presentation: Two brothers, aged five and eleven, presented with severe chemical burns over multiple limbs following application of TBHT whilst overseas. The reaction was mildest in areas of initial and single application – with hypopigmentation and ACD – and most severe in areas where TBHT was applied sequentially – with skin loss and pustule formation. In addition, some wounds were complicated by infection. Management consisted initially of Hydrogel and Paraffin Gauze, with oral antibiotics, followed by anti-microbial foam and Nanocrystalline silver dressings, and finally, topical steroid cream. Dermatology was consulted regarding chemicals with cross-reactivity to be avoided in addition to PPD-containing products.  Conclusion: The use of PPD is widespread throughout the world, but its presence and concentration is often unknown. Due to difficulty enforcing regulations in other jurisdictions, increasing public awareness of its potential complications, including long-term scarring risk, is likely to be the most effective means of preventing burns secondary to PPD sensitisation.


Rachael completed her Undergraduate MBBS at the University of Western Australia in 2014.She has recently moved from Adult General Surgery to Paediatric General Surgery and is currently a resident at Sydney Children’s Hospital.

Burn injuries secondary to cryolipolysis: Freezing fat, burning skin.

Dr Lisa Murphy1, Mr David Read1,2, Ms Margaret Brennan1, Mrs Linda Ward2,3, Mrs Kathleen  McDermott2

1Royal Darwin Hospital, Tiwi, Australia, 2National Critical Care and Trauma Response Centre, Tiwi, Australia, 3Menzies School of Health Research, Tiwi, Australia


Background:The number of Australians seeking cosmetic procedures is increasing each year, particularly non-surgical or minimally invasive cosmetic procedures. One of the newer technologies used to reduce the appearance of fat deposition is cryolipolysis or ‘cool sculpting’; a process designed to cause fat cell necrosis but leave skin unharmed, by cooling soft tissues to 0 to -7 C degrees.
Methods:We present two cases of burns associated with cryolipolysis in female patients seeking fat removal treatment. Both patients received cold thermal burn injuries to their treated areas, one of which was superficial dermal and treated conservatively and one of which was deep dermal and required debridement. A review of the literature surrounding these particular types of injury was performed, which were hand searched for articles reporting complications.
ResultsThe results of the literature search revealed three cases of reported skin necrosis with cryolipolysis use; one do-it-yourself home fat-freezing abdomen skin necrosis, one beauty salon flank cryolipolysis-induced necrosis and one plastic surgery clinic lateral thigh cryolipolysis-induced necrosis.

Discussion: Burn injury or skin necrosis does not appear to be a commonly-reported complication of cryolipolysis and it was not listed among the potential complications on the device’s website in the cases we treated. However, the observation of two such injuries in two months at our unit highlights that these injuries are certainly possible and may be more common than previously thought. Complications of cosmetic procedures; their regulation, monitoring and credentialing are increasingly topical issues as the demand for such procedures increases.


Jennifer is a Set 1 Plastic Surgical Trainee in Victoria. She is dual qualified in both medicine and dentistry. She aims to be involved in preventative programs/initiatives to plastic surgical & burns related injuries.

Review of Extravasation Injuries in Paediatric Patients: Management and Outcomes

Dr Michelle Chen1, Professor Roy Kimble1, Ms Kristen Storey1

1Lady Cilento Children’s Hospital, Brisbane, Australia


Introduction: Intravenous access for medications and fluid therapy is commonplace in paediatric hospital admissions. However, despite the clinical guidelines (CPG) and education, extravasation injuries (EI) and associated complications still occur.

Description: Over the last decade, research and advancement of medical technology have changed how complex wounds are managed.
This study is a retrospective review of medical records of extravasation/ infiltration injuries reported on risk management database (RiskMan) at a quaternary paediatric hospital.

The database has identified over 80 cases of extravasation injuries from May 2017 to May 2018. The review aims to determine the demographics, pattern of injuries and examine the management methods employed, and follow-up of outcomes.

The hospital has a mandatory education program on prevention, identification, and management of EIs for clinical staff. This study will also evaluate the effectiveness of mandatory education and identify potential methods in reducing extravasation injury incidences.

Discussion: What is the current pattern of extravasation and infiltration injuries seen in paediatric population?
Does education effectively prevent, and assist staff in correctly identifying extravasation and infiltration injury?
Current management methods, future trends and outcomes.

Conclusion: The majority of EIs are managed conservatively with anti-microbial dressings and regular reviews with generally favorable cosmetic and functional outcome. Surgical intervention is required in rare cases, however, still essential.

Justification for presentation:
I hope this study raises awareness for extravasation/infiltration injuries and the vital role of burns specialty knowledge. A retrospective review is a learning opportunity to improve and provide the best care for our patients.


Dr. Michelle Chen is a paediatric surgery Principal House Officer at the Lady Cilento Children’s Hospital, with a special interest in paediatric surgery, trauma, and burns.

Exhausted! A five year review of the characteristics and clinical outcomes of paediatric vehicle exhaust burns.

Dr Bronwyn Griffin1, Ms Angelin Ooi2, Professor Roy Kimble1,3, Dr  Aoife Rice3

1Centre For Children’s Burns And Trauma Research, South Brisbane, Australia, 2University of Queensland, Herston, Australia, 3Lady Cilento Children’s Hospital, Brisbane, Australia


Vehicle exhaust burns are one of the more common causes of contact burn injuries in children. These burns have previously been associated with slower time to re-epithelialisation and higher rates of grafting compared to other burn mechanisms (Roberts et al. 2002; Rajan et al. 2011).

Queensland Paediatric Burns Registry data from January 2013 to December 2017, was used to identify burns. This paper aims to identify current demographics, injury characteristics and clinical outcomes to better inform prevention interventions.

In total n=259 children presented with an exhaust burn, significantly more male (n= 193, 75%, compared to other burn mechanisms, 59%, p<0.001) with a median age of seven years (IQR=3-11 years). The majority of cases occurred from motorbike (n=215), other vehicles included car (n=26), quadbike (n=5), mower (n=5). Median Total Body Surface Area (TBSA)% was 1% (IQR=1 to 1), highest TBSA 6%. Body region differed significantly by age group, 0-4 years more frequently injured hands (n=37, 45.7%) and >10 years more frequently lower limb (n=73, 82%, p<0.001). Patients with exhaust burns had higher proportions of theatre interventions compared to other burns mechanisms (33% versus 7%). Overall, 75% of burns occurred in metropolitan areas, however higher proportions of burns occurring in non-metropolitan areas required grafting (51% versus 31%, p=0.004). Exhaust burns were significantly more likely to occur in summer and spring (p<0.001).
Exhaust burns remain a serious risk of injury to children. Although small in size, these burns are associated with significantly higher morbidity, particularly patients in rural settings. A collaborative effort with community partners will highlight these findings in a prevention campaign.

1. Roberts, R, Kelson, E, Goodall-Wilson, D, Kimble, R 2002, ‘Motorcycle exhaust burns in children’, Burns, vol. 28, no. 4, pp. 367–369.
2. Rajan, V, Abeyasundara, SL, Harvey, JG, Holland, AJA 2011, ‘Exhaust burns in children’, Burns, vol. 37, no. 2, pp. 273–276.


Dr Griffin has had over 10 years’ experience Nursing in paediatric emergency departments across Australia before completing her PhD with the Centre of Children’s Burns and Trauma Research. Dr Griffin is now the Clinical Research Manager of the Centre which is now located at Lady Cilento hildren’s Hospital, supervising 18 researchers. Her work supports the integrated spectrum of paediatric burn and trauma care from injury prevention/public health, first aid, acute care, scar management and psychosocial and cultural influences

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

Dr Dinuksha De Silva1, Dr Aruna Wijewardena1

1Royal North Shore Hospital, Sydney, Australia


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).

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.


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

In a Flash- A Case Report of Magic Paper Burns

Dr Alicia Miers1, Mr James  Brannigan2, Professor Roy Kimble1

1Pegg Leditschke Children’s Burns Centre, Lady Cilento Children’s Hospital, South Brisbane, Australia, 2University of Queensland, Brisbane, Australia


“Flash Paper” is a nitrocellulose paper commonly used in magicians’ routines and accessible in magician supply stores. The intrinsic nitrate concentration determines its pyrotechnic characteristics, and this form of nitrocellulose is classified as an explosive (National Centre for Biotechnology Information 2009).

The fast disappearing Flash Paper can be used to give the illusion of throwing fire when lit by a hidden ignition source. Performed correctly, the stunt causes no injury to the magician, however, improper use of the material has the potential to cause serious injury, burning at a maximum temperature of approximately 209°C (He, et al. 2017; DeHaan 1975).

This is a case report of a thirteen year old admitted to a quaternary children’s hospital in Brisbane, Australia with burns sustained when a roll of Flash Paper ignited on his lap while experimenting with friends. Partial thickness burns were sustained involving bilateral medial thighs, the left side of the face and left pinna as well as mild conjunctival burns to his left eye. His treatment required an inpatient admission, ophthalmology treatment and outpatient burns dressings. Re-epithelialisation had occurred to the majority of his wounds including his conjunctival burn by Day 9. On follow up at Day 16, there was complete re-epithelialisation of all wounds.

Reports of Flash Paper burns have not to date been published. While the purchase of nitrocellulose products is restricted to persons over 18 years. Precautions must be taken in order to ensure the safety of novice magicians employing this easily obtainable form of nitrocellulose.

Reference List
DeHaan, JD 1975, ‘Quantitative Differential Thermal Analysis of Nitrocellulose Propellants’, Journal of Forensic Science, Vol 20, Issue 2, pp243-253.
He, Y., He, Y., Liu, J., Li, P., Chen, M., Wei, R., & Wang, J. (2017). Experimental study on the thermal decomposition and combustion characteristics of nitrocellulose with different alcohol humectants. Journal of Hazardous Materials, Vol 340, 202-212.
National Centre for Biotechnology Information 2009, Nitrocellulose. Bethesda: PubChem Compound Database, viewed February 12 2018, <>


Dr Alicia Miers is a Senior House Officer with the Paediatric Surgery, Urology and Burns Unit at Lady Cilento Children’s Hospital.

Can’t Handle the Heat: Public Holidays and An Increased Incidence of Coal Burns in the Paediatric Population

Dr Courtney  Hall1, Dr  Teagan   Fink1, Ms  Alenka  Paddle1, Associate Professor  Warwick  Teague1

1Royal Children’s Hospital, Victoria , Flemington, Australia


Australians love camping, and a campfire is often an integral component of this past-time. Unfortunately, coal and flame burns related to campfires are a significant cause of burns in the Paediatric population. We undertook a retrospective review from July 2015 to April 2018 at the Royal Children’s Hospital, Victoria to examine trends in the incidence of such burns, and their temporal relationship to public holidays.

During this three-year period 78 children sustained burns from either flames or hot coals in relation to campfires. 38 (50%) of these were sustained on a public holiday or within a ‘public holiday period’ (defined for this study as the weekend immediately before or after a public holiday). The vast majority of burns (89%, n=68) were sustained by contact with hot coals after the fire had been extinguished. More than 96% of burns were treated entirely in the outpatient setting with only 3 patients requiring surgical management.

Whilst building a campfire is an exciting and popular pastime for many Australians, the data above suggests a lack of public understanding in regards to appropriate fire safety measures. We propose an increase in public education targeted around public holidays where there is a known increase in the incidence of such injuries within the paediatric population.

To our knowledge there are no previous studies presenting the relationship outlined above.

Key words
Burn, coal, flame, paediatric, public holiday, prevention


I am a third year resident with a keen interest in Plastic and Reconstructive Surgery and Burns. During my three month residency at the RCH, I undertook research whilst working on these units units due to my special interest in the subject.

Vaporisers: A Danger in Paediatric Burns

Dr Teagan Fink1, Dr Courtney Hall1, Ms Alenka Paddle1, A/Prof Warwick Teague2

1Plastic and Maxillofacial Surgery Unit, Royal Children’s Hospital, Parkville, Australia, 2Burns Unit, Royal Children’s Hospital, Parkville, Australia


Hot steam vaporisers are increasingly common in Australia, however are also a cause of paediatric burns. To understand the incidence and health burden of these burns in children, we undertook retrospective data collection from inpatient and outpatient treatment settings at a large tertiary paediatric hospital. Across the time period of May 2015 to May 2018, we analysed demographics, location of burn, total body surface area (TBSA), activity at the time of the burn, first aid measures, surgical management and complications.

Of the 37 vaporiser burns in children, 98% of cases were under the age of 2 years and 73% were males. All were managed in the outpatient or day surgery setting. The most common location was the hand (92%), affecting less than 1% TBSA. Three cases sustained 3 or 4% TBSA burns. 27% of burns required surgical management, and complications were found in 14% of cases. More than half of the children were unsupervised when the burn was sustained. Unfortunately, just 19% of children received the recommended first aid for burns in Australia, highlighting an important education point.

Despite these products being marketed for relief of symptoms of nasal congestion and viral illnesses, there currently exists little clinically sound evidence to support these claims. Furthermore, our study shows these items can cause significant morbidity in a paediatric burns population. More research is required to fully characterise the risk benefit profile of this household item, however caution is essential when using a vaporiser around children.


Dr Teagan Fink is a Plastic and Maxillofacial Surgical Resident at the Royal Children’s Hospital.  During her six month rotation with the unit, she undertook research into paedatric burns.  She is also a Surgical Resident at St Vincent’s Hospital Melbourne.

Mitigating fire casualties in cities around the world

Ms Elise Kempler1, Professor Peter Maitz2, Professor Palmer Bessey3

1Sydney Medical School, The University of Sydney, , Australia, 2Burns Research Group, ANZAC Research Institute, Burns and Reconstructive Surgery Unit, Concord Repatriation General Hospital, Sydney Medical School, The University of Sydney, , Australia, 3The William Randolph Hearst Burn Center, New York Presbyterian Weill Cornell Medical Center, , United States


Introduction Prevention of deaths and injuries from fires in buildings is a public health responsibility of municipal governments. The purpose of this study was to understand how high-density cities across the globe carry out this mission.
Methods: Publically available city-specific data sources were surveyed for New York (NYC), Sydney (SYD), London (LON), Tokyo (TOK), Singapore (SIN), Hong Kong (HK), Barcelona (BAR), Berlin (BER) and Paris. Data on building codes, firefighting resources, use of warning systems and education were recorded.
Results: NYC averages 270 structural fires per M population annually and 8.5 fire deaths per M. SIN averages 520 and 0.7, LON 670 and 4.3, and BAR 780 and 18. LON and TOK promote smoke detector installation in almost every room. NYC installs devices in public housing. SYD requires them in caravans. Paris had no requirement until 2016. BER will require them from 2020. SIN and HK have no requirement. HK requires rescue floors in “supertall” buildings. Education is commonly provided to schoolchildren and other groups. Home visits are conducted for the aged. LON uses software to estimate areas of high fire risk and educational need. NYC and TOK have the largest firefighting departments.
Summary and conclusion: There has been a remarkable global shift in fire prevention. The use of smoke detectors is a common strategy to reduce fire deaths and burns for most high-density cities, but requirements vary widely. Lack of standardised data makes it difficult to evaluate the efficacy of these and other measures.


Elise Kempler is a final-year medical student at the University of Sydney who has been based at both Royal Prince Alfred Hospital and Dubbo Base Hospital. Elise recently completed an 8-week Elective clerkship at Weill Cornell Medical College in New York City. This included a placement in Surgery at the William Randolph Hearst Burn Center where she shadowed burns surgeon Professor Palmer Bessey and witnessed the consequences of structural fires. As a first time visitor to the city, Elise was intrigued by the fire escapes – the zig-zag metal stairs that iconically hug the exteriors of many apartment buildings. She contemplated their utility. Today Elise will be presenting the findings of the epidemiological question of how major population centres such as New York City address fire safety and prevent burns casualties.



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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