Patient or Prisoner?: Acute Burn Injuries in Prisoners-The Birmingham Burns Centre Experience

Increased risk of violence and self-harm means prisoners are a vulnerable population with complex health needs. They account for a small proportion of patients with burn injuries; however, present a unique set of challenges. This study investigates the incidence, pattern and outcomes of burn injuries in prison population. Prisoners referred from 2010 to 2021 were identified using the International Burn Injury Database (iBID). Patient demographics, burn injury characteristics and outcomes were collected. Patients were then stratified based on mechanism of injury, treatment modality (surgery/conservative), hospital admission (inpatient/outpatient), and compliance with outpatient follow-up, for subgroup analyses. Sixty-eight prisoners sustained burns during the study period, with a median age of 28.5 years and TBSA of 3%. The majority were male (98.5%) and required hospital admission (75%). Scalds were the most common injury type (77.9%) and assault the most frequent cause of burns (63.2%). Eighteen patients (26.5%) underwent a surgical procedure and there were two mortalities. Of patients for whom follow-up was planned, 22% attended no appointments, with a further 49% of prisoners missing at least one appointment. Relative to patients managed nonoperatively, prisoners undergoing surgery had a longer stay and all attended outpatient follow-up appointments. Prisoners represent a unique population with exceptional challenges. Attention should be given to protecting vulnerable patients at risk of assault, education of prison staff around burn prevention and first aid, and ensuring that prisoners are able to access burns follow-up to minimize long-term sequelae. Opportunities exist to aid this such as the adoption of telemedicine.

Outpatient and Minor Burn Treatment

Burn injuries are common; most burn injuries may be considered minor and are suitable for outpatient management. Steps should be taken to ensure that patients managed in this way still retain access to the full burns multidisciplinary team, and that admission remains an option if complications develop or according to patient preference. Modern antimicrobial dressings, outreach nursing teams, and the use of telemedicine means that the number of patients that can be safely managed without hospital admission is likely to increase further.

A descriptive survey of operating theatre and intensive care unit temperature management of burn patients in the United Kingdom

BACKGROUND

Patients with major burns lose the normal thermoregulatory function of their skin. They exhibit profound changes in metabolism which aim to compensate for the heat loss associated with water loss through burnt skin. Although these changes in physiology are well documented, the optimal methods for temperature management in both the Operating Theatre and Intensive Care Unit are less clear.

METHODS

We distributed a survey consisting of 19 questions to all burn units and centres in the United Kingdom with the aim of ascertaining perception of both hypo and hyperthermia, as well as methods used to manage both of these scenarios.

RESULTS

In the Operating Theatre, most respondents stated that they measured core temperature (82%); either alone (33%) or in conjunction with peripheral temperature (49%). In the Intensive Care Unit, most respondents measured both core and peripheral temperature (67%), with only a small minority not measuring core temperature (13%). Taking into consideration all professional groups, patients were considered hypothermic if their body temperature was less than 36.2°C (+/-0.7°C). On average, a patient was considered hyperthermic if their body temperature was above 38.8°C (+/-0.6°C).

CONCLUSION

Differences in perception between the professional groups surveyed did not reach clinical or statistical significance. In both the Operating Theatre and Intensive Care Unit, hypothermia was most often managed by increasing the ambient room temperature whereas hyperthermia was most often managed by giving paracetamol. As far as we are aware, this is the first study of the management of altered thermoregulation in major burn patients in the United Kingdom.

A prospective study of time to healing and hypertrophic scarring in paediatric burns: every day counts

BACKGROUND

It is commonly accepted that burns taking longer than 3 weeks to heal have a much higher rate of hypertrophic scarring than those which heal more quickly. However, some of our patients develop hypertrophic scars despite healing within this 3-week period.

METHODS

We performed a prospective study of 383 paediatric burns treated non-operatively at a regional burns centre over a 2-year period from May 2011 to April 2013. Scar assessment was performed by a senior burns therapist using the Vancouver Scar Scale.

RESULTS

Overall rates of hypertrophic scarring were 17.2%. Time to healing was the strongest predictor of developing hypertrophic scarring, and the earliest hypertrophic scar developed in a patient who was healed after 8 days. The risk of hypertrophic scarring was multiplied by 1.138 for every additional day taken for the burn wound to heal. There was a trend towards higher rates of hypertrophic scarring in non-white skin types but this did not reach statistical significance.

CONCLUSIONS

The risk of hypertrophic scarring increases with every day and, therefore, every effort should be made to get the wound healed as quickly as possible, even within the traditional 3-week period usually allowed for healing. We believe that the traditional dogma of aiming for healing within 3 weeks is overly simplistic and should be abandoned: in paediatric burns, every day counts.

TRIAL REGISTRATION

Not applicable.

Extended applications of gauze-based negative pressure wound therapy in hand surgery: a review of five cases

Negative pressure wound therapy (NPWT) is an established treatment for a wide variety of acute and chronic wounds. Although the exact mechanism of action is still undefined, the proposed benefits of NPWT have been well described in the literature and include improved wound perfusion, granulation and reduction of oedema and bacteria. Here we describe a series of five challenging cases where NPWT dressings were applied for both elective and traumatic wounds of the upper limb. We describe the application of the dressing and the benefits seen in our patients. We believe the patients would have had inferior outcomes if managed by the best alternative conventional dressings.

DECLARATION OF INTEREST

All named authors hereby declare that they have no conflicts of interest to disclose.

Iron burns: a problem in adults as well as children

Burns from domestic irons are potentially preventable injuries which can result in significant morbidity. Several studies have reported these injuries in children but there are no reports to date in adults. Epidemiology, management and outcome of these injuries is described, and possible preventative strategies are discussed. We present a retrospective case note review of 50 adult and paediatric patients with electric iron burns. Cases were identified from data collected for a national burns database. Information regarding demographics, burn characteristics, treatment and long term outcome was gathered from the medical records. 42 children and 8 adults sustained a burn from an iron during the 4-year study period. The majority of paediatric patients were under 4 years of age. Most burns were small (< 1% TBSA) but despite this 30 (60%) patients were admitted to hospital and 13 (26%) required at least one surgical procedure. In children, most burns occurred at home and were commonly due to pulling the flex or knocking the iron from its surface. In adults, 50% of injuries were associated with epilepsy. Burns from domestic irons are relatively common and cause significant morbidity despite their small size. A bimodal presentation is seen with injuries occurring either before the age of 4 years or during adulthood, when they are typically associated with an underlying medical condition. Education campaigns and design features such as a retractable cord may further reduce the incidence of this type of burn.

Management of iatrogenic full thickness electrical burn in a preterm neonate using W-plasty technique combined with a median sternotomy incision

Burns in the neonatal period are rare and most commonly due to iatrogenic causes. We report a case of a preterm neonate who sustained a full thickness electrical burn following the use of a temporary pacing pad. The case was complicated by significant co-morbidities and the need for cardiac surgery. We describe the surgical management of the case, using excision and closure in the form of a W-plasty. We discuss the reasons for this surgical decision and the importance of managing complex cases such as this on an individual basis.

Incorporating multi-source feedback into a new clinically based revision course for the FRCS(Plast) exam

BACKGROUND

Exit exams for completion of surgical training are demanding and have relatively low pass rates with many candidates requiring multiple attempts.

AIM

To establish a new, clinically based exam preparation course, utilising multi-source feedback, to identify candidates at risk of failure and improve pass rates.

METHODS

We describe the process of establishing a new, unique, clinically based exam preparation course incorporating multi-source feedback from examiners, patients, nurses and other trainees. We present the course results as well as the exam results for each candidate and analyse the results of the multi-source feedback.

RESULTS

Nine candidates have so far successfully completed both the preparation course and the FRCS(Plast) exam. Success in the exam preparation course accurately predicts success in the FRCS(Plast) exam. Nursing staff and patients tend to give higher scores than examiners and trainees. The majority of marginal failures from the course went on to pass the exam, indicating that the course allows candidates to successfully address weaknesses identified on the course.

CONCLUSION

A clinically based exam preparation course utilising multi-source feedback allows identification of candidates at risk of failing a surgical training exit exam and allows targeted training in order to maximise pass rates.

Adherence to referral criteria for burns in the emergency department

OBJECTIVE

To audit the referral patterns of burns in an emergency department compared with national referral guidelines.

METHODS

A retrospective case note audit of patients attending an emergency department with a diagnosis of "burn" in a 1-year period.

RESULTS

Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well.

CONCLUSION

Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.

The safety of nanocrystalline silver dressings on burns: a study of systemic silver absorption

INTRODUCTION

Wound dressings containing silver have been in widespread use for many years. However, there are few quantitative data on the systemic absorption of silver or whether there is associated clinical risk.

OBJECTIVES

To assess systemic silver levels when Acticoat dressings containing nanocrystalline silver were used, and to determine whether increases in such levels were associated with haematological or biochemical indicators of toxicity.

METHOD

A prospective, single-centre, open-label study of 30 patients with relatively small burns that required skin grafting. Serum silver levels were measured before, during and at discontinuation of the use of the Acticoat dressings, and again at 3 and 6 months following completion of treatment.

RESULTS

The median total postoperative wound size was 12% of the total body surface area. The median time to maximum silver levels was 9 days. The median maximum serum silver level was 56.8 microg/l. The median serum level at 6 months was 0.8 microg/l. There were no haematological or biochemical indicators of toxicity associated with the silver absorption observed in this study.

CONCLUSION

This study has confirmed our view that Acticoat products are safe for use on burns and they remain a standard part of treatment at our centre.

Rickettsia: an unusual cause of sepsis in the emergency department

Mediterranean spotted fever (caused by Rickettsia conorii) is one of the tick-borne rickettsioses. It is prevalent in southern Europe, Africa and central Asia and may also be seen in travellers returning from these areas. It presents with various non-specific symptoms, including fever, maculopapular rash, headache, myalgia or diarrhoea and vomiting. A visible eschar at the site of the tick bite is characteristic but not present in all cases. There is no test that reliably confirms the disease in its early stages and diagnosis is often made on clinical grounds. Delay in diagnosis and in providing correct antibiotic treatment increases the mortality rate of this condition. Emergency clinicians should be aware of the possible diagnosis in travellers returning from endemic areas in order to start the correct treatment as early as possible and minimise subsequent complications and mortality.

Clinical placements for medical students: factors affecting patients' involvement in medical education

Many medical students now have contact with patients from the very beginning of their course and the increasing numbers of medical students means that more and more patients will be exposed to students during their medical treatment. This paper presents the attitudes of 281 patients towards medical students encountered in a primary or secondary care setting. Particular attention is paid to consent, types of procedures undertaken and the title given to the medical student. The study showed that the likelihood of patients agreeing to be involved in medical education depended on the patient, the student and the procedure being undertaken. Recommendations have been made to the university on the basis of the results with the aim of maximizing patient involvement and satisfaction in order to further medical student education.