Conservative management of burn injuries in older patients with flammacerium

Dr Shivani Aggarwala1,2, Dr Andrea Issler-Fisher1,2, Professor Peter Haertsch1,2, Professor Peter  Maitz1,2

1Concord Burns Unit, Sydney, Australia, 2University of Sydney, Camperdown, Australia


Early debridement of burn eschar is associated with a reduction in burn related mortality but is not appropriate in all circumstances. Older patients (over 65 years old) constitute a vulnerable group where a conservative approach may be more appropriate.
Age has been consistently shown to be a strong predictor of in-hospital mortality. Older patients generally present with multiple comorbidities, reduced functional reserve capacity and consequently a diminished ability to adapt to circumstances of increased physiological demand such as post burn injury. They are often in a higher risk category for general anaesthesia. Aggressive, early debridement and skin grafting in modifying the host inflammatory response and reducing the risk of infection still remains highly controversial in the elderly population. Often post-surgical complications such as pneumonia, malnutrition and poor mobility outweigh the benefits of early debridement and grafting.

Flammacerium is an ideal biological dressing in such cases where early operative management is not suitable. Flammacerium is a combination of silver sulphadiazine and cerium nitrate and forms a firm eschar over the wound, protecting it from bacterial ingress whilst keeping the underlying wound moist and promoting healing. It binds and denatures the lipid protein complex (LPC), the burn wound toxin thought to cause immunosuppression and a significant contributor of late mortality in burn injuries.

This case series presents patients over 65 years of age with burn injuries greater than TBSA 20% in which conservative treatment with flammaserium proved to be safe and efficacious with minimal morbidity and no mortality.


Shivani is an unaccredited registrar currently working at Concord Burns Unit. She has a keen interest in Burns and reconstructive surgery.

Best practice management of burns during pregnancy, and our experience over 20 years at a tertiary burns unit

Dr Grace Brownlee1,2, Dr Matthew Lyon1,2, Dr  Carl Lisec1,2

1Professor Stuart Pegg Adult Burns Centre, The Royal Brisbane And Women’s Hospital, Herston, Australia, 2Faculty of Medicine, The University of Queensland, St Lucia, Australia


Burns during pregnancy are rare, and present a unique management challenge given the physiological changes associated with pregnancy. Major burns in pregnant women are particularly uncommon in developed countries, and therefore are infrequently reported in the literature. As a result, there is a paucity of information regarding incidence, management principles, maternal and foetal risk factors, and overall outcomes. In a literature search, we were unable to identify any Australian publications on this topic. We conducted a literature review to identify best practice management, and reviewed our experience with burns in pregnant patients over a 20 year period at the Professor Stuart Pegg Adult Burns Centre (PSPABC).

Between 1997 and 2017, 1723 females were admitted to the PSPABC, of which 13 (<0.01%) were also pregnant. The TBSA affected in these patients ranged from 0.5 – 30% and the most common mechanism of injury was scalding from a hot liquid (50%). Nine of these patients received operative management of their burns, three of which also underwent caesarean section deliveries. No maternal or foetal deaths occurred as a direct result of burns injuries.

It is evident that the case profile and management challenges in our Burns unit are vastly different from those of developing countries, who have similarly examined their experiences. We are less practiced in the management of severe and life threatening burns in pregnant patients, as they are simply not prevalent. Development of a national/local evidence based guideline is required but challenging due to the relatively low incidence of major burns in pregnancy in Australia.


Dr Grace Brownlee is a Resident Medical Officer currently undertaking her PGY2 year at The Royal Brisbane and Women’s Hospital. She completed her medical education at the University of Queensland in 2016.

Burns in the extreme geriatric population

Dr Morgan Haines1, Dr  Aruna  Wijewardena1, Dr  Robert  Gates1

1Royal North Shore Hospital, St Leonards, Australia


Background: Patients aged over 85 are a growing population in the burns units of developed nations (Lumenta et al. 2008). This age group is highly susceptible to burns which are more severe than in younger patients (Albornoz et al. 2011). Methodology: A retrospective observational study conducted between 2013 to 2017 in the tertiary burns unit at Royal North Shore Hospital in Sydney, Australia.

Results: 1570 patients were treated in total. 54 patients were aged 85  and over, median age 88 years. The majority of patients had scald burns. Mortality during admission was 7%. We also report parameters of post burn management such as the time to theatre, time to first graft, number of surgeries and number of outpatient visits. Discussion: Literature describing elderly burns outcomes most often includes patients ranging from approximately 65 years (Duke et al. 2015; Alboronz et al. 2011; Wibbenmeyer et al. 2001). However the extreme geriatric burns have issues and outcomes distinct to younger geriatrics (Jeschke et al. 2016; Shariff et al. 2015). The fact that this population group is rapidly expanding combined with our rate of in-hospital mortality of 7% indicates the need for relevant information that can guide clinical decisions.

Conclusion: There is a paucity in the data describing outcomes following extreme geriatric burns. To our knowledge, this is the largest study of burns focussing on the the extreme elderly. Our data describe up to date information on the epidemiology, aetiology and management of burns in patients aged over 85.


Dr Haines is a junior medical officer in the Severe Burns Unit at Royal North Shore Hospital. As a medical student Morgan was selected to join an Interplast surgical outreach team to Fiji. Morgan hopes to pursue a career in Burns and Plastic Surgery and has an interest in global surgery.

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.

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


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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