Major burns in adults: a practice review.

There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation room impacts on the effectiveness of continuing care in the intensive care unit. The scope of the present practice review is the immediate management of the adult patient with severe burns, including inhalation injury and burn shock. The article uses an illustrative case to highlight recent developments including advanced airway management and the contemporary approach to assessment of fluid requirements and the type and volume of fluid resuscitation. There is discussion on new options for pain relief in the ED and the principles governing the early stages of burn intensive care. It does not discuss minor injuries, mass casualty events, chemical or radiation injuries, exfoliative or necrotising conditions or frost bite.

Is the use of a powered dermatome an aerosol-generating procedure (AGP)? Implications for personal protection against COVID-19 virus.

INTRODUCTION: Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol. METHODS: We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated. RESULTS: The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray. CONCLUSION: Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area. LAY SUMMARY: A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Necrotizing myositis: highlighting the hidden depths - case series and review of the literature.

BACKGROUND: Necrotizing myositis (NM) is a life-threatening emergency. It causes focal muscle necrosis without abscess formation or extensive involvement of the overlying fascia and soft tissue. It is a clinical diagnosis requiring a high index of clinical suspicion. Usual presentation can readily be mistaken to represent more benign pathologies such as muscular injury, viral myopathy or deep venous thrombosis. The clinical course following initial misdiagnosis is rapid deterioration into profound sepsis and progressive multiorgan failure. Prompt treatment is associated with favourable outcomes, but early diagnosis is challenging due to initial absence of cutaneous signs and symptoms. Delayed referral to surgeons with appropriate expertise results in higher morbidity and mortality. The cornerstones to treatment are complete surgical debridement, intensive care management and accurate antimicrobial therapy. METHODS: We report four cases of NM demonstrating classical scenarios of initial misdiagnosis, delays in referral and review by an experienced surgeon. A review of the current literature to aid with overall management is also included. RESULTS: Review of literature that revealed the most common presentation was antecedent prodromal flu-like symptoms followed by rapidly progressing focal muscle pain. Patients were initially misdiagnosed followed by rapid deterioration into profound sepsis before surgical opinion was obtained. CONCLUSION: NM is a rare and potentially fatal disease that must be considered in the differential diagnoses of the young, healthy patient with acute limb pain and fever. A high index of suspicion will facilitate earlier management and reduce morbidity and mortality.

Postsurgical Pyoderma Gangrenosum Versus Necrotizing Fasciitis: Can We Spot the Difference?

BACKGROUND: Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris. Exceptionally, it can be precipitated by surgery alone, and this entity has been described as postsurgical pyoderma gangrenosum (PSPG). Cases of PSPG in the literature are rare. METHODS: We performed a retrospective review of the current literature on PSPG and highlight some observed differences between these conditions. We also present our experience of PSPG imitating an infectious process post reduction mammoplasty. RESULTS: Although PSPG can demonstrate fever, malaise, systemic signs, and serology that mimic the sepsis of necrotizing fasciitis, we identify some features that can aid diagnosis of pyoderma gangrenosum in the absence of pathergy (which is pathognomonic). These include premorbid inflammatory bowel disease, hematological malignancy, or inflammatory polyarthritis; the exquisite and disproportionate pain associated (in particular within surrounding normal skin); symmetrical changes on both breasts; specific histopathological changes with absence of microorganisms; cutaneous wounds demonstrating an ulcerated, violaceous, and undermined edge; and, in this case, bilaterally spared nipple-areola complexes suggesting progression within continuous skin up to but not across incision lines. CONCLUSIONS: We hope that, in encouraging a higher index of suspicion, prompt diagnosis, and accurate treatment, a better outcome for both patient and surgeon can be achieved in future cases.