Ten-year Brisbane experience in petrol burns: a preventable health burden.

Petrol is one of the most widely used and freely available fuels in use in developed countries today. This study examines the clinical details and demographics of adults with petrol burns over a 10-year period with a view to identifying any trends. The majority of petrol burns were due to human error and thus theoretically preventable. This study determined that the young male (aged 16-25) is most at risk, mainly through the misuse of petrol. The best method of prevention of these burns might be education targeting this group of population. This study provides a basis upon which effective intervention programmes can be designed.

Management of extravasation injuries.

BACKGROUND: Various agents have been implicated in causing tissue necrosis after intravenous infusions have extravasated. These include solutions of calcium, potassium, bicarbonate, hypertonic dextrose, cytotoxic drugs and antibiotics. Views on management of these injuries differ, and range from a non-operative conservative approach to early debridement and grafting. METHODS: A retrospective review was undertaken of the hospital files of patients with extravasation injuries seen in three Australian hospitals. Nine patients were identified, and their management and long-term follow up are reported. RESULTS: Age ranged from 17 days to 60 years. Two patients received their injuries from solutions containing isotonic dextrose/saline. The other seven patients received injuries from a variety of solutions including calcium gluconate (n = 1), parenteral nutrition (n = 1), sodium bicarbonate (n = 1), immunoglobulin (n = 1), gentamicin and penicillin (n = 1), flucloxacillin (n = 1), and the chemotherapeutic agents epirubicin and cyclophosphamide (n = 1). The sites involved included the dorsum of the right foot (n = 3), the dorsum of the left foot (n = 3), the right groin (n = 1), the right hand (n = 1) and the left hand (n = 1). Four patients were managed by delayed debridement and split skin grafting, while five were treated non-operatively. Prolonged scar management was necessary in seven of the nine patients. Final results were satisfactory in all patients who received skin grafting and in all patients who were managed conservatively. CONCLUSIONS: Management of extravasation injuries should be conservative if possible. Delayed debridement and split skin grafting is required if the area of skin loss is extensive. Scar management remains a problem. Prevention of these injuries with the education of both medical and nursing staff remains the ultimate aim.

Determinants of death following burn injury.

BACKGROUND: Burn care has changed considerably. Early surgery, nutritional support, improved resuscitation and novel skin replacement techniques are now well established. The aim of the study was to establish whether changes in management have improved survival following burn injury and to determine the contributory factors leading to non-survival. METHODS: This was a retrospective outcome analysis of data collected from a consecutive series of 4094 patients with burns admitted to a tertiary referral, metropolitan teaching hospital between 1972 and 1996. RESULTS: The overall mortality rate was 3.6 per cent. This decreased from 5.3 per cent (1972--1980) to 3.4 per cent (1993--1996) (P = 0.076). The risk of death was increased with increasing burn size (relative risk (RR) 95.90 (95 per cent confidence interval 12.60--729.47) if more than 35 per cent of the total body surface area was burned; P < 0.001) increasing age (RR 7.32 (3.08--17.42) if aged more than 48 years; P < 0.001), inhalation injury (RR 3.61 (2.39--5.47); P < 0.001) and female sex (RR 1.82 (1.23--2.69); P = 0.003). Operative intervention (RR 0.11 (0.06--0.21); P < 0.001) and the presence of an upper limb burn (RR 0.53 (0.35--0.79); P = 0.002) decreased the risk. CONCLUSION: Modern burn care has decreased the mortality rate. Increasing burn size, increasing age, inhalation injury and female sex increased, while operative intervention and an upper limb burn decreased, the risk of death. Presented to the 10th Congress of the International Society for Burn Injuries, in Jerusalem, November 1998

Self-inflicted burn injuries: an 11-year retrospective study.

The burns unit at the Royal Brisbane Hospital accepted a total of 2275 admissions from 1986 to 1996. During this 11-year period, 65 cases of self-inflicted burn injury were treated, which made up 2.9% of the total number of admissions. A mortality rate of 21.5% (14 patients) is noted, with all patients dying after admission to the hospital. A common feature of people that self-inflict burn injuries is a psychiatric history, with many patients having histories of self-harm or suicide attempts. Two distinct groups were identified--those with suicidal intent and those with intent of self-harm. Those patients with self-inflicted injuries have an increased mean of 31.4% total body surface area burned as compared with those patients whose injuries are accounted for as accidental, which have a mean total body surface area burned of 10%. Additionally, the mean length of stay in the hospital for patients with self-inflicted injuries was 40 days for acute injuries, which is prolonged; the mean length of stay for acute injuries that were not self-inflicted was 14 days. This investigation discovered 3 cases of repeated self-inflicted burn injury.

Cicatricial, postburn ectropion and exposure keratitis.

Exposure keratitis can lead to infectious keratitis, corneal perforation, blindness and disfigurement. Chronic exposure of the cornea can occur following facial burns that cause eyelid ectropion. This complication can be difficult to diagnose in the unconscious patient. Five patients have undergone lid ectropion release to 11 eyelids in the early postburn period over the past 5 years. One patient required repeat release. Full-thickness skin grafts were used for the lower eyelid and no graft failure occurred. Operations were performed between 30-50 days postburn. Plastic wrap was used in one patient as a temporary dressing to maintain corneal hydration until surgery could be performed. All the patients were noted to have exposure keratitis on ophthalmological review. Patients most at risk are those with large area burns that include the face, who require prolonged intensive care support. It is important to look out for the development of eyelid ectropion, which should be corrected when first diagnosed to prevent disabling, sight-threatening eye injury.

Self-inflicted burns.

Self-inflicted burns are a regular source of admissions to burns units world wide. This study examines the characteristics and outcomes of those who deliberately burn themselves. The medical records of all patients admitted to the Royal Brisbane Hospital Burns Unit and identified as having suffered a self-inflicted burn between 1990 and 1995 were reviewed. The records of patients who doused themselves with flammable liquid between 1984 and 1995 were examined as a separate group. Of 1072 admissions there were 44 cases (4.1 per cent) of deliberately self-inflicted burns. Average age was 30 yr with an average total burn surface area (TBSA) of 30 per cent (range 1-98 per cent). Schizophrenia, depression and personality disorder were diagnosed in 71 per cent. Alcohol intoxication was common in the rest. Suicide attempters were almost all male and the majority (60 per cent) were diagnosed with a major psychiatric illness. Self-mutilators suffered much less serious burns and none died. Self-inflicted burns accounted for 24 per cent of burns admitted to the intensive care unit. Self-immolation with flammable liquid resulted in severe burns with a 45 per cent mortality. A number of differences was demonstrated between those patients who had attempted suicide and those who had deliberately burnt themselves without suicidal attempt. Self-immolators constitute a considerable proportion of major burns admitted to this unit.

Pattern of burn injury in hang-glider pilots.

High-voltage electrical injury has been well documented in a number of situations, such as the occupational hazard of linesmen and construction workers, and in the context of overhead railway power lines. Two cases of hang-glider pilots contacting 11,000-volt power lines have recently been treated in the Royal Brisbane Hospital Burns Unit. They demonstrate an interesting pattern of injury, not described in current burns literature, involving both hand and lower abdominal burns. Both patients sustained full-thickness patches of burn injury, with underlying muscle damage and peripheral neurological injury. This distribution of injury seems to be closely related to the design of the hang glider.

Vibrio cholerae non-O1 primary septicaemia following a large thermal burn.

A case of primary septicaemia with a Vibrio cholerae not agglutinable with O group 1 sera is reported in a burn patient. This appears to be the first reported case of this organism causing infection in a burn patient. The case is discussed, highlighting the difficulties encountered in treating this unexpected organism and the course of the infection in this patient. It is probable that the organism was obtained during first aid for the burn wound.

Electric iron contact burns in an Australian paediatric population.

Accidental burn injury is common among children. Contact burns are the second most frequent cause of burns in children and electric iron contact burns constitute a substantial proportion of this group. A prospective analysis of electric iron burns presenting from 1988 to 1991 was conducted. The 38 iron burns treated during this period represented 19% of contact burns treated. The mean age of injury was 19 months. The male to female ratio was 1.1:1 and 80% involved the upper limb. Twenty-five per cent required operation. All burns occurred in the child's own home with the majority (74%) occurring in the central living areas while the child was supervised (45%). The child was most likely to be injured by touching the iron directly or pulling the cord. A substantial number of burns occurred even after the iron was switched off. Education should be directed towards the caregivers of young children emphasizing the need to use and store irons in areas to which children do not have free access. Powerpoints should be placed so that children cannot reach the cord. Manufacturers should provide insulated pads in which to store the iron and a retracting cord to help prevent the cord being within a child's reach.

Preventing morphological disturbances in burn-scarred children wearing compressive face garments.

Continuous external compression in the form of elasticized garments is a well-accepted and substantiated form of management for postburn hypertrophic scarring. Children who have sustained deep partial thickness and/or full skin thickness burns to the face and head are frequently prescribed elasticized compressive face garments in the post-acute stage of their recovery. Recurrent concerns expressed by parents prompted investigation into the frequency of sleep disturbances, such as snoring subsequent to the application of face garments, and the possibility of changes to the developing dentition. This preliminary study utilized a single case design to demonstrate the effectiveness of a bimaxillary mouthguard in circumventing such problems.

A quantitative assessment of blood loss in burn wound excision and grafting.

A prospective study was performed that allowed a quantitative estimation of blood loss in excision and grafting of adult burn injuries. The average value for blood loss was 9.2 per cent of the patient's estimated blood volume or 387 ml per 1 per cent burn excised and grafted. There was no exponential increase in blood loss as the percentage excised and grafted increased apart from proportionality and there was no statistical difference between males and females for burns excised and grafted days 1-14 after injury or greater than 14 days after injury. It was therefore concluded that a useful working figure is 400 ml whole blood or 10 per cent of patient blood volume is lost per 1 per cent full thickness burn excised and grafted for an adult. These values do not apply to the very young, the very old and those patients who have bleeding disorders, and when using various methods to limit blood loss. This figure allows adequate cross-matched whole blood to be available preoperatively.

Multiple resistant Staphylococcus aureus.

Burn wound sepsis is still a common cause of death in burn injuries. Eighty percent of this infection is with colonisation from the patient and twenty percent as a result of cross infection. Most of the mortality is due to virulent cross infection. Pseudomonas has almost disappeared and multiple resistant staphylococcus aureus is the main pathogen today. It can cause loss of skin grafts and septicaemia, particularly due to colonisation of intravenous lines. The risk increases with the time since the burn injury. Early excision and grafting is important. With a large burn it is not possible to do this in one session and so the risk is increased with a compromised patient. Maintenance of a good diet and vitamin supplements is important, preferably orally or through a naso-gastric tube. Parenteral nutrition increases the risk of infection. Clinical infection is combated by good cleaning procedures, preferably with chlorhexidine solution and the application of a good topical agent such as Silvazine. The presence of bacteria in the wound must be monitored. Strict barrier nursing and personal hygiene, particularly hand washing, are the mainstay of cross infection prevention. Antibiotics may be required, monitored by blood cultures. Documenting MRSA is a good way to monitor the unit's infection prevention programme. The main preventive measures are early referral, early excision and grafting, good nutritional support, good topical agents and barrier nursing.

Escharotomy in burns.

UNLABELLED: The need for escharotomies is relatively common in the treatment of burn injuries. The need arises because the tight eschar may interfere with the circulation to a limb causing demarcation and loss of the limb or in the case of the chest, may cause interference with respiration such that the expansion in the lungs is interfered with causing atelectasis and pneumonia. In the neck the oedema in the tissue may cause obstruction to the trachea. Indications for escharotomy rest on clinical grounds with tension in the limb under the burn and the state of circulation to the periphery being important. Added to this is the use of Doppler ultrasound, clinical presence of peripheral pulses and at times compartmental pressure measurements. The aim of the escharotomy is to release the pressure over the involved deeper tissues and to restore their circulation. TECHNIQUE: Under sterile conditions make incisions through the eschar until the tissue gapes such as to release the pressure particularly on the vascular supply. These should avoid flexion increases and be designed to release pressure in all compartments if necessary. In the case of electrical burns this may need to be combined with a fasciotomy for diagnostic and therapeutic purposes. Bleeding must be controlled and the escharotomy is then treated as a burn injury being packed with Silvazine cream. Elevation of the limbs is important also to help limit the oedema.

Altered pharmacokinetics of tricyclic antidepressants in burns.

A case of self-inflicted burns which occurred in the setting of a major depression with psychotic features is described. The case emphasises the difficulties in utilising plasma (serum) tricyclic antidepressant levels to determine adequacy of treatment and risk of toxicity. The case discussion demonstrates the altered pharmacokinetics of tricyclic antidepressants that can occur during disorders such as burns, surgery and medical illness.

Epidemiology of burns due to domestic flammable agents.

An analysis of the epidemiological factors relating to domestic flammable agents has shown that 17.7 per cent of admissions over a 5-year period were involved in domestic flammable injuries; 87.7 per cent of the patients were male, with 38.9 per cent being young males between 12 and 19 years old. Petrol and diesel accounted for 56.8 per cent of the burns and the average body surface area burned was 17.7 per cent. Most commonly the face, hands and limbs were burned, and the average length of stay was 18.25 days, 69.2 per cent of the burns were due to human error and were thus potentially preventable, 21.2 per cent had predisposing conditions with 8.9 per cent being due to alcohol. It was considered that the strategies to prevent these burns injuries should be aimed particularly at young males.

Measuring pressure under burns pressure garments using the Oxford Pressure Monitor.

Pressure garments are used extensively in the treatment of hypertrophic scarring following burn injuries. The Oxford Pressure Monitor was used to measure garment-scar interface pressure (mmHg) using a number of fabric types over various body parts. The results indicate a wide range of pressure values between different garments and body parts with the greatest pressures found over the dorsum of hands and feet. The problems of achieving 'optimal pressure' over hypertrophic scarring are discussed with emphasis on the need for more accurate measuring equipment.

Foam ear protectors for burnt ears.

Foam ear protectors were developed at the Royal Brisbane Hospital for use with selected patients with burns to the ears. The protectors assist in preventing pressure necrosis of the ear and damage to skin grafts. They permit visualization of the ears after grafting and allow the patient to sleep in a side-lying position if desired.

Homograft skin banking--current practices and future trends.

Homograft skin remains a very successful technique for covering major burns. This paper reviews current techniques of harvesting, microbiological testing, freezing and thawing of the skin, that lead to its optimal use. Recent advances, especially the use of homograft skin in combination with split skin and skin cultures, will add to the effectiveness of homograft skin application.