Biobrane™ versus acticoat™ for the treatment of mid-dermal pediatric burns: a prospective randomized controlled pilot study.

OBJECTIVES: The management of pediatric mid-dermal burns is challenging. Anecdotal evidence suggests Biobrane™ (UDL Laboratories, Inc., Sugar Land, TX) may expedite epithelization, reducing the requirement for skin grafting. Our standard management for burns of this depth is Acticoat™ (Smith and Nephew, St. Petersburg, Fl, USA). No publications are known to compare Biobrane™ to Acticoat™ for treatment of mid-dermal burns. METHODS: A prospective, randomised controlled pilot study was conducted, comparing Biobrane™ to Acticoat™ for mid-dermal burns affecting ≥ 1% Total Body Surface Area (TBSA) in children. Mid-dermal burns were confirmed using Laser Doppler Imaging within 48 hours of injury. Participants were randomized to Biobrane™ with an Acticoat™ overlay or Acticoat™ alone. RESULTS: 10 participants were in each group. Median age and TBSA were similar; 2.0 (Biobrane™) and 1.5 years (Acticoat™), 8% (Biobrane™) and 8.5% TBSA (Acticoat™). Use of Biobrane™ had higher infection rates (6 children versus 1) (P = 0.057) and more positive wound swabs, although not significant (7 children versus 4) (P = 0.37). Healing time was shorter in the Biobrane™ group, this was not significant (19 days versus 26.5 days, P = 0.18). Median dressing changes were similar (5 versus 5.5) (P = 0.56). Skin grafting requirement was greater in the Acticoat™ group (7 versus 4 children, P = 0.37) and similar in % TBSA (1.75% TBSA). CONCLUSION: This pilot study suggests that the use of Biobrane™ for mid-dermal burns in children may be associated with increased risk of infection but appears to decrease the time to healing and therefore the need for skin grafting compared to Acticoat™ alone.

Comparison of a traditional and non-traditional residential care facility for persons living with dementia and the impact of the environment on occupational engagement.

BACKGROUND: Dementia residential facilities can be described as traditional or non-traditional facilities. Non-traditional facilities aim to utilise principles of environmental design to create a milieu that supports persons experiencing cognitive decline. This study aimed to compare these two environments in rural Australia, and their influence on residents' occupational engagement. METHODS: The Residential Environment Impact Survey (REIS) was used and consists of: a walk-through of the facility; activity observation; interviews with residents and employees. Thirteen residents were observed and four employees interviewed. Resident interviews did not occur given the population diagnosis of moderate to severe dementia. Descriptive data from the walk-through and activity observation were analysed for potential opportunities of occupational engagement. Interviews were thematically analysed to discern perception of occupational engagement of residents within their facility. RESULTS: Both facilities provided opportunities for occupational engagement. However, the non-traditional facility provided additional opportunities through employee interactions and features of the physical environment. Interviews revealed six themes: Comfortable environment; roles and responsibilities; getting to know the resident; more stimulation can elicit increased engagement; the home-like experience and environmental layout. These themes coupled with the features of the environment provided insight into the complexity of occupational engagement within this population. CONCLUSION: This study emphasises the influence of the physical and social environment on occupational engagement opportunities. A non-traditional dementia facility maximises these opportunities and can support development of best-practice guidelines within this population.

An assessment of early Child Life Therapy pain and anxiety management: A prospective randomised controlled trial.

INTRODUCTION: Burns remain extremely painful and distressing in young children. The consequences of poorly managed pain and anxiety can be life-long. Whilst Child Life Therapy (CLT) has been shown to be effective in many situations, few studies have looked at the effectiveness of CLT in regard to reducing pain and anxiety in children undergoing burn dressing changes. METHODS: A prospective, randomised controlled trial was conducted, comparing CLT versus standard care in relation to pain and anxiety scores of children undergoing their initial burn dressing change. Pain and anxiety were assessed by an independent observer and questionnaires completed by the child, parent/caregiver and nursing staff. RESULTS: 50 subjects were recruited in each treatment group; median age 2.3 years (CLT) and 2.2 years (standard care). The median total body surface area (TBSA) burnt was 0.8% (CLT) and 0.5% (standard care). The majority were partial thickness dermal burns (88% CLT, 94% standard care). Rates of parent anxiety and pre-procedural child pain and anxiety were similar. Combined and scaled pain and anxiety scores in the CLT group were significantly less than in the standard treatment group (p=0.03). Whilst pain was significantly better in the CLT group (p=0.02), fear scores, wound outcomes and the need for skin grafting were not statistically different in either group. CONCLUSIONS: The presence of a Child Life Therapist, with their ability to adapt to the environment, the child and their family, significantly reduced the experience of pain during paediatric burn dressings.

Prospective, randomised controlled trial comparing Versajet™ hydrosurgery and conventional debridement of partial thickness paediatric burns.

INTRODUCTION: Conventional surgical debridement of burn wounds consists of tangential excision of eschar using a knife or dermabrasion until viable dermis or punctate bleeding occurs. The Versajet™ (Smith and Nephew, St. Petersburg, FL, USA) hydrosurgery system has also been advocated for burn wound debridement, with the suggestion that enhanced preservation of dermal tissue might reduce subsequent scarring. METHODS: A prospective randomised controlled trial was undertaken comparing Versajet™ to conventional debridement. After excluding those with facial burns, 61 children ≤16 years of age undergoing debridement and skin grafting for partial thickness burns were recruited. Adequacy of debridement was assessed by 2mm punch biopsies taken pre- and post-debridement. Surgical time, percentage graft take at day 10, time to healing, post-operative infection and scarring at 3 and 6 months were assessed. RESULTS: Thirty-one children underwent conventional debridement and 30 debridement using Versajet™. There was a significant difference in the amount of viable dermal preservation between the two groups (p=0.02), with more viable tissue lost in the conventional group (median 325 µm) versus the Versajet™ group (median 35 µm). There was no significant difference between graft take at day 10 (p=0.9), post-operative wound infection (p=0.5), duration of surgery (p=0.6) or time to healing after grafting (p=0.6). Despite better dermal preservation in the Versajet™ group, there was no significant difference between scarring at 3 or 6 months (p=1.0, 0.1). CONCLUSIONS: These findings suggest that Versajet™ hydrosurgery appears a more precise method of burn wound debridement. Although dermal preservation may be a factor in reducing subsequent hypertrophic scarring, there were no significant differences found between scarring at 3 or 6 months after-injury.

Chemical burns in children: Aetiology and prevention.

BACKGROUND: Chemical burns account for a small proportion of total burns in children, but may require specific first aid and different modes of prevention. METHODS: A retrospective study between 2006 and 2012 of children ≤16 years treated with chemical burns at a specialist paediatric burn centre. Data were extracted from a prospectively maintained database. RESULTS: 56 episodes of chemical burns occurred during the study period. The majority (54%) occurred in boys. There were 39 (72%) patients <10 years and 17 (39%) ≥10 years. Median total body surface area burnt was 1% with nine (16%) patients requiring skin grafting. Only 24 (45%) had adequate first aid. The majority (n=46, 82%) of chemical burns occurred in the domestic setting, especially in the <10 years age group (P=0.052). Non-intentional exposure of chemicals by an unattended child accounted for half of all (n=22, 49%) chemical burns <10 years of age. Eight (47%) burns in patients ≥10 years resulted from self-harm. The most common aetiological agents were household cleaners and aerosols in the younger and older age groups respectively. CONCLUSION: Chemical burns remain infrequent but potentially preventable. These burns mainly occur in the domestic setting due to non-intentional exposure of household chemicals in children <10, and due to deliberate self-harm in children ≥10. The use of child-resistant packaging, similar to that used for medications, and improved parental practices could help decrease the incidence of burns in children <10.

Medical management of paediatric burn injuries: best practice part 2.

Burns remain a leading cause of injury in the paediatric population in Australia despite efforts in prevention. Advances in surgical management include novel debridement methods and blood conserving techniques. Patients with severe burns (>20%) remain significantly more complex to manage as a result of extensive alterations in metabolic processes. There appears increasing evidence to support the use of pharmacological modulators of the hyper-metabolic state in these patients. The management of a child with burns involves acute, subacute and long-term planning. This holistic approach seems optimally co-ordinated by a Burns Unit in which each discipline required to provide care to these children in order to achieve optimal outcomes is represented.

Catheter balloon-related urethral trauma in children.

AIM: To review urethral injuries arising from incorrect balloon inflation in children undergoing urinary catheterisation. METHOD: Retrospective review from 1995-2006. Children who sustained catheter-related injury at The Children's Hospital at Westmead were identified through medical records database and reviewed. RESULTS: Six patients were identified over the 11-year period. All six were boys. Age ranged from <1 month to 16 years. All but one occurred in hospital. All injuries were confirmed by urethrogram. Bulbar and prostatic urethra was involved in an equal number of children studied. Three patients required suprapubic catheters. Follow-up imaging revealed healing without stricture in all patients. CONCLUSION: Balloon-related urethral trauma can be avoided by educating health-care professionals on proper placement and confirmation of position of catheter. Though there were no long-term complications noted, a temporary suprapubic diversion may be needed.

Gastroduodenal emphysema.

Pneumatosis intestinalis of the foregut is a very rare finding. It may represent emphysematous gastritis secondary to inflammatory conditions or gastric emphysema secondary to proximal foregut obstruction and high intragastric pressure. We present a case of gastroduodenal pneumatosis secondary to partial duodenal obstruction in an infant with Down's syndrome.