Burns

Editorial Board

2010-09-01

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2010-09-01

Mass casualty incidents with multiple burn victims: Rationale for a Swiss burn plan

2010-09-01

Abstract: Introduction: Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.Methods: Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.Results: Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20–30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.Conclusions: Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.

Use of Acticoat™ dressings in burns: What is the evidence?

Roba Khundkar, Claudia Malic, Tim Burge — 2010-09-01

Abstract: The virtues of silver as an antimicrobial agent have been known for some time. Various silver containing dressings are currently used for the treatment of wounds. Introduced in the late 1990s, Acticoat™ is a nanocrystalline silver dressing developed to overcome some shortcomings of the older dressings by providing sustained release of silver up to 7 days. We aim to determine the level of evidence available in the literature in view of recent increased usage of Acticoat™.A Medline search was conducted to identify articles evaluating the use of Acticoat™ in burn wounds. A level of evidence adapted from the Oxford Centre for Evidence-Based-Medicine was assigned to each of these articles.Only one study was considered to be LOE 1, which is a multicentre randomised controlled trial comparing Acticoat™ against Silver Sulfadiazine. One further randomised control trial was downgraded to LOE 2 due to a wide confidence interval. Twenty studies (66%) were LOE 5 of which 6 were case reports and 14 were in vitro/animal studies.The available LOE 1 study demonstrates that Acticoat™ has better antimicrobial activity compared to another available silver dressing. Other studies suggest Acticoat™ has fewer adverse effects and reduces healing times. Its ease of application and low frequency of change makes it an ideal dressing in burn wounds. More well designed and properly reported randomised controlled trials are essential for informed clinical decision-making.

Emotional associations with skin: Differences between burned and non-burned individuals

A. Titscher, D.B. Lumenta, L.P. Kamolz, M. Mittlboeck, M. Frey — 2010-09-01

Abstract: Introduction: The appearance of skin is crucial for our physical and psychological integrity, and is strongly associated with our emotional self-awareness. Burn victims have to cope with negative and even threatening sensations resulting from the changed appearance of their skin after injury and also linked to experiences during the treatment.The aim of this study was to analyse differences regarding the emotional associations with skin in burn victims (burn group) to persons not having subdued any burn (control group).Methods: In the first instance over 960 volunteers were recruited for the rating of emotional associations with skin in the control group and thereby a representative profile for non-injured individuals. In the second part, 44 burn patients of the Vienna Burn Center answered the same questionnaire. The quantitative rating of emotional associations with skin was performed with a newly designed questionnaire using a semantic differential on eight dimensions with a 5-point scale system.Results: Both groups have positive associations with skin. One significant difference (p=0.0090, Chi-square test for trend) was the overall rating of the item “importance”: for burn victims skin is more “important” than for controls. Patients with visible burns tended to put more emphasize on the possible exposure to danger (“threatened”) of skin, and patients with ≥20% TBSA rated skin as more “noticeable” and “strong” as compared to small burns (<20% TBSA). Patients with burns to the face, hands and neck (“visible burns”) were more likely to judge skin as threatened item.Discussion: Our poll suggests that despite long treatment, rehabilitation and even near-death experiences burn patients continue to have positive associations with skin. This in turn, should encourage all specialists dealing with burns to engage in a continuous follow-up as well as enhance psychological and social support.

Topical negative pressure therapy: Does it accelerate neovascularisation within the dermal regeneration template, Integra? A prospective histological in vivo study

Naiem S. Moiemen, Jeremy Yarrow, Dia Kamel, Daniel Kearns, Derek Mendonca — 2010-09-01

Abstract: Background: The use of topical negative pressure (TNP) dressings with dermal regeneration template (DRT), Integra, has improved outcomes and simplified aftercare. Previous clinical studies have suggested accelerated vascularisation; with a reduction in the duration of the 1st stage after the application of Integra, from 2 to 4 weeks to as little as 4 days, but with no histological evidence. However, histological studies, without TNP, have shown that vascularisation occurs between the second and the fourth week. This study set out to examine histologically the rate of DRT neovascularisation when combined with TNP.Methods: Eight patients with nine reconstruction sites were enlisted. Unmeshed Integra and fibrin sealant to promote adherence were used. TNP was applied for the duration between the 1st and the 2nd stages. Patients underwent serial biopsies on days 7, 14, 21 and 28 post-application. The biopsies were stained with H&E and endothelial markers CD31 and CD34. Template vascularisation was assessed as a percentage of the template depth in which patent, canalised vascular channels could be demonstrated.Results: The median percentage of the template depth which demonstrated canalised channels was 0%, 20%, 61% and 80% for days, 7, 14, 21 and 28, respectively.Conclusion: The application of TNP dressings to dermal templates can reduce shearing forces, restrict seroma and haematoma formation, simplify wound care and improve patient tolerance. However, this study could not demonstrate that TNP accelerates neovascularisation as verified by the presence of histologically patent vascular channels.

Treatment of post-burn neuropathic pain: Evaluation of pregablin

Lesley Wong, Leslie Turner — 2010-09-01

Abstract: Burn survivors have described a type of pain, usually after wound healing, that has characteristics of neuropathic pain. This pain is not well treated with conventional medications. Pregabalin has had reported success in treating diabetic and post-herpetic neuropathic pain. We report our experience with pregabalin for the treatment of post-burn neuropathic pain. A retrospective review of patients treated with pregabalin in a burn outpatient clinic was undertaken. A numerical pain scale was administered to each patient prior to and after treatment to determine efficacy. Side effects and reasons for discontinuation were noted. Out of 24 patients 4 patients were lost to followup, 5 patients discontinued taking pregabalin and 2 patients had incomplete data for evaluation. Of the remaining 13 patients, 69% (11) had a reduction in pain score after treatment. In addition, 2 of the patients who discontinued use had a pain score which decreased to 0. Pregabalin is a well-tolerated, effective means of treating post-burn neuropathic pain. Time to achieve effective dosing is relatively quick and there is a range of dosing available. The mechanism, pharmacokinetic benefits, and potential benefits are discussed. Further studies will be needed to look effects on quality of life and reduction of opioid use.

Contribution of bacterial and viral infections to attributable mortality in patients with severe burns: An autopsy series

2010-09-01

Abstract: Bacterial infections are a common cause of mortality in burn patients and viral infections, notably herpes simplex virus (HSV) and cytomegalovirus (CMV) have also been associated with mortality. This study is a retrospective review of all autopsy reports from patients with severe thermal burns treated at the US Army Institute of Research (USAISR) burn unit over 12 years. The review focused on those patients with death attributed to a bacterial or viral cause by autopsy report. Of 3751 admissions, 228 patients died with 97 undergoing autopsy. Death was attributed to bacteria for 27 patients and to virus for 5 patients. Bacterial pathogens associated with mortality included Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus. This association with mortality was independent of % total body surface area burn, % full-thickness burn, inhalation injury, and day of death post-burn. Bloodstream infection was the most common cause of bacteria related death (50%), followed by pneumonia (44%) and wound infection (6%). Time to death following burn was ≤7 days in 30%, ≤14 days in 59% and ≤21 days in 67%. All of the viral infections associated with mortality involved the lower respiratory tract, HSV for 4 and CMV for 1. Four of these 5 patients had evidence of inhalation injury by bronchoscopy, all had facial and neck burns, and 2 had concomitant Staphylococcus pneumonia. Time to death following burn ranged from 14 to 42 days for the 5 patients. Despite advances in care, gram negative bacterial infections and infection with S. aureus remain the most common cause of bacteria related mortality early in the hospital course. Viral infections are also associated with mortality and numbers have remained stable when compared to data from prior years.

A reliable and valid outcome battery for measuring recovery of lower limb function and balance after burn injury

Vidya Finlay, Michael Phillips, Fiona Wood, Dale Edgar — 2010-09-01

Abstract: Introduction: The measurement of recovery after burns to the lower limbs is hampered by an absence validated injury specific tools. This research aimed to select and validate a battery of outcome measures of recovery after lower limb burn injury (LLBI).Method: Reliability study: Reliability of the single leg stance (SLS), the Timed Up and Go (TUG) and the tandem walk (TW) tests were measured using a test–retest trial involving 28 patients with LLBI. Validity study: Clinical data from 172 patients with LLBI were used to compare changes in each LL outcome measure with changes in the Burn Specific Health Scale-Brief (BSHS-B).Results: All tests, except the SLS test with eyes closed, demonstrated excellent inter-rater reliability (ICCs=0.81–0.93). The TUG and the TW-forwards tests were shown to be valid and to provide additional information to the BSHS-B when combined as a battery. The TW-backwards test was redundant while the SLS and ankle DF measures did not correlate highly with the BSHS-B.Conclusion: This study shows that the TUG test and the TWF are reliable and valid in the burns population and along with the BSHS-B form a useful test battery for measuring recovery from LLBI.

Pathway genetic load allows simultaneous evaluation of multiple genetic associations

Ryan M. Huebinger, Harold R. Garner, Robert C. Barber — 2010-09-01

Abstract: Objective: Despite the general success of genome-wide association studies, much heritability remains unidentified in many disease states. Some of this ‘missing’ heritability may lie in epistatic interactions among multiple loci, which are typically ignored. We utilized a method for simultaneous evaluation of epistatic interactions between allelic variations within genes confined to a single pathway, which we have termed as pathway genetic load (PGL).Methods: In separate analyses, we evaluated the risk for sepsis and for death associated with alleles at six loci in the TLR4 signaling and response pathway previously known or suspected to be linked to the development of sepsis after traumatic injury. We evaluated 155 patients with ≥15% TBSA burns and without significant non-burn trauma [ISS≤16], traumatic or anoxic brain injury or spinal cord injury, who survived >48h post-admission. Clinical data were collected prospectively and candidate genotypes were determined by TaqMan assay.Results: After adjustment for burn size, inhalation injury, age, gender and race, PGL was associated with increased probability for complicated sepsis (aOR=1.59; 95%CI=1.11–2.29; p=0.011) and death (aOR=1.75; 95%CI=1.11–2.76; p=0.017).Conclusion: Relative size and variability of aORs indicate greater power to detect genetic associations with PGL compared to the analysis of loci individually by multivariate logistic regression.

Laser Doppler Imaging prediction of burn wound outcome in children: Is it possible before 48h?

Khanh Nguyen, Diane Ward, Lawrence Lam, Andrew J.A. Holland — 2010-09-01

Abstract: Background: Laser Doppler Imaging (LDI) assists in prediction burn wound outcome. Previous data has validated this technique in children between 48 and 72h after burn.Aim: To evaluate the ability of Laser Doppler Imaging (LDI) to predict burn wound outcome in paediatric patients prior to and after 48h from the time of injury.Methods: A prospective evaluation was performed in 400 children over a 12-month period that presented to our burns clinic. Patients were divided into two groups: those that presented within 48h of injury (n=160) and those that presented after 48h (n=240). Patients were reviewed until healing had occurred or operative intervention was required.Results: The median age of the patients was 2.4 years (range 0.1–15.9 years). For patients who presented within 48h, the sensitivity and specificity of the LDI was 78% and 74% respectively compared to 75% and 85% for those scanned after 48h. This difference was not statistically significant.Conclusions: LDI predicted burn wound outcome in children within 48h of the burn wound. Moderate degrees of movement, infection, whether first aid was administered and type of dressing did not impact on the accuracy of LDI.

Videocapillaroscopy in postburn scars: In vivo analysis of the microcirculation

Ezio Nicola Gangemi, Riccardo Carnino, Maurizio Stella — 2010-09-01

Abstract: Objective: The aim of the study was the evaluation in vivo of the differences between the microcirculatory characteristics of the postburn scar and the healthy skin.Methods: Twelve patients with postburn scars were included in the study, evaluating fifteen scar areas and twelve healthy skin areas by means of contact optical probe videocapillaroscopy. The examined areas for each patient were the right and the left upper limb. Capillary density, length and diameter, together with capillary distribution pattern (punctiform, reticular, directional) and the presence of microhaemorrhages and neoangiogenesis were studied.Results: The results were obtained by two different researchers using the capillaroscope's software. Capillary loop diameter and length, capillary distribution pattern and presence of neoangiogenesis were found to be significantly increased in postburn scars compared with controls. There were also significant differences between hypertrophic tissue in the active phase and the one in the remission phase for capillary diameter and presence of neoangiogenesis.Conclusion: Videocapillaroscopy showed “in vivo” a change in local microcirculation architecture using a microscope. Patients with hypertrophic burn scars showed a variety of microcirculatory changes, often clustered in a characteristic pattern of abnormally oriented, dilated capillaries and neoangiogenetic phenomena. This methodology is highly likely to be of value in the assessment and prognostication of burn outcome.

The role of fibrinogen in aggregation of platelets in burn injury

G.Y. Levin, M.N. Egorihina — 2010-09-01

Abstract: Spontaneous aggregation of platelets is considerably enhanced in the acute period after burn. The changes in indices-induced aggregation of platelets are non-uniform and not significant statistically. Thermal trauma is accompanied by the development of hyperfibrinogenemia and an increase in the level of oxidised fibrinogen. We studied the influence of fibrinogen concentration and the degree of its oxidation on aggregation of platelets. It was shown that the level of aggregation of platelets greatly depends on the concentration of fibrinogen (non-oxidised and oxidised) plasma. The possible mechanisms of these effects are investigated.

Reduction of plasma granzyme A correlates with severity of sepsis in burn patients

2010-09-01

Abstract: The risk of mortality is high in burn patients and correlates with age, burn area extent, and sepsis. Immunosuppression has been reported to occur after severe burn. Cytotoxic cells possess specialized granules containing perforin and a group of serine proteases (granzymes). Granzyme A is a serine protease constitutively expressed by γδ and NK cells, in agreement with their functional cytolytic potential. In vitro studies have shown that GrA may be released extracellularly during cytotoxic cell degranulation, indicating the activation of cytotoxic cells. The aim of our study was to determine plasma GrA activity in burned patients and to verify if decreased GrA levels were associated with poor prognosis.Specific GrA activity was tested in the plasma of burned and healthy subjects by esterase assay. Plasma GrA was significantly decreased in septic rather than in nonseptic burn patients and in healthy subjects (p<0.05 and p<0.001, respectively).At day 3 plasma GrA was significantly lower in nonsurvivor than in survivor septic patients (p<0.05). The value of 91mOD showed a sensitivity of 100% and a specificity of 84% in differentiating survivor from nonsurvivor septic patients.Because this is a retrospective study, Granzyme A is not a confirmed predictor of septic outcome after burn, but its determination could give useful information about the development and severity of sepsis.

Prevalence of multidrug-resistant organisms recovered at a military burn center

2010-09-01

Abstract: Infections caused by multidrug-resistant (MDR) pathogens are associated with significant morbidity and mortality in patients with burn injuries. We performed a 6-year antibiotic susceptibility records review from January 2003 to December 2008 to assess the prevalence of MDR isolates by pathogen at the US Army Institute of Surgical Research Burn Center. During the study period Acinetobacter baumannii (780 isolates [22%]) was the most prevalent organism recovered, followed by Pseudomonas aeruginosa (703 isolates [20%]), Klebsiella pneumoniae (695 isolates [20%]), and Staphylococcus aureus (469 isolates [13%]). MDR prevalence rates among these isolates were A. baumannii 53%, methicillin-resistant S. aureus (MRSA) 34%, K. pneumoniae 17% and P. aeruginosa 15%. Two isolates, 1 A. baumannii and 1 P. aeruginosa, were identified as resistant to all 4 classes of antibiotics tested plus colistin. A. baumannii isolates recovered from patients with burns greater than 30% of total body surface area (TBSA) were more likely to be MDR (61%) with no significant difference for P. aeruginosa and K. pneumoniae. A higher proportion of MDR P. aeruginosa isolates were recovered from respiratory specimens compared to blood specimens (24% vs. 9%) while the opposite was true for MRSA (35% vs. 54%). A comparison of A. baumannii recovered during hospitalization days 1–5 and 15–30 revealed higher MDR levels as length of stay increased (48% vs. 75%) while no significant trends were observed for P. aeruginosa and K. pneumoniae. A similar pattern was observed for MDR A. baumannii levels for the facility between 2003 and 2005 and 2006–2008 (39% vs. 70%), with no significant increase in MDR P. aeruginosa and MDR K. pneumoniae. Increasing antibiotic resistance patterns of the most prevalent isolates recovered during extended hospitalization, impact of % TBSA and other clinical parameters may affect empirical antimicrobial therapy and patient management decisions during treatment.

Imipenem-resistant Pseudomonas aeruginosa strains carry metallo-β-lactamase gene blaVIM in a level I Iranian burn hospital

Mohammad Ali Bahar, Shohreh Jamali, Ali Samadikuchaksaraei — 2010-09-01

Abstract: Introduction: In this study, we aimed to determine the distribution of blaVIM and blaIMP transferable genes in Pseudomonas aeruginosa isolates from infected burn wounds in an Iranian level I burn care center. These genes confer imipenem resistance and increase the mortality rate of burn patients.Methods: P. aeruginosa isolates from burn patients were tested for antibiotic susceptibility with Kirby-Bauer disk diffusion method and for production of metallo-β-lactamase (MBL) by EDTA disk method. DNA was purified from isolates with positive MBL results and underwent PCR for detection of blaVIM and blaIMP genes.Results: MBL was produced by 23 imipenem-resistant isolates and blaVIM gene was detected in all of these isolates. None of the isolates carried blaIMP gene. Mortality rate of infection with MBL-producing Pseudomonas strains was 82.6% in this hospital while the mortality rate for non-MBL-producing Pseudomonas was 22.7%.Conclusion: We found that all MBL-producing isolates in this hospital carry blaVIM gene. This result is similar to the previous Iranian study and emphasizes the importance of VIM family of MBLs in Iran. Timely identification of these strains and strict isolation methods can prevent spread of this transferable gene to other Gram-negative bacteria and prevent the subsequent outbreak of high mortality.

Intralesional pentoxifylline as an adjuvant treatment for perioral post-burn hypertrophic scars

2010-09-01

Abstract: Pentoxifylline (PTF), a methylxanthine derivative, has therapeutic use as an antifibrotic agent. In vitro, PTF inhibits the production of collagen and reduces the proliferation of fibroblasts in hypertrophic scars. This study aimed to evaluate changes in the elasticity of hypertrophic scars in the peribuccal area in burned patients, who presented with mouth-opening limitation. Eighteen patients were divided into two groups. The case group (n=10) was treated with PTF 1mgml−1, while in the control group (n=8) no treatment was performed. Measurements of mouth opening (lip-to-lip and tooth-to-tooth distances in mm) were taken, before and after five therapeutic sessions with pentoxifylline with weekly intervals. The variations of these measures (Δ%) were calculated and submitted to statistical analyses. There was a significant improvement in the opening of the mouth, in vermilion distance (V=3.20mm) as much as the dental distance (DD=4.19mm) in the treated group, than in the control group. It was noted that pentoxifylline increases the elasticity of hypertrophic scars in the perioral area.

Percutaneous collagen induction therapy: An alternative treatment for burn scars

2010-09-01

Abstract: Objective: This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring.Background: Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis.Patients: A total of 16 consecutive patients (average age: 37±15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring.Intervention: PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation.Outcome measures: The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention.Results: On average, patients rated their improvement as a mean of 80% better (±15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively.Conclusions: This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.

Extracorporeal shock waves, a new non-surgical method to treat severe burns

A. Arnó, O. García, I. Hernán, J. Sancho, A. Acosta, J.P. Barret — 2010-09-01

Abstract: Extracorporeal shock wave treatment (ESWT) increases perfusion in ischaemic tissues, stimulates growth factors, decreases inflammation and accelerates wound healing. It is a safe technique classically used in urology and orthopaedic surgery with success, but there is still limited literature regarding its use in the management of burns.Purpose: The aim of this study is to analyse the effect of ESWT on deep partial/full thickness burns in patients attended at our emergency burn unit.Materials and methods: We performed two ESWT sessions in 15 patients with <5% TBSA (total body surface area) deep partial/full thickness burns, on the third and fifth day after injury; prior to each session, we used laser Doppler imaging (LDI).Results: Of all treated burns, 80% healed uneventfully prior to 3 weeks; as many as 15% required surgical debridement and grafting and 5% developed hypertrophic scarring. After one ESW session, burns had a significant increase in perfusion, objectivated by the LDI images.Conclusions: Extracorporeal shock wave therapy emerges as a new non-invasive, feasible, safe and cost-effective method in deep partial/full thickness burns. It may decrease the need of surgery and therefore the morbidity of the patient. There is a strong need for more studies to establish the optimal timing and dosage of treatment.

The severe burns patient with tracheostomy: Implications for management of dysphagia, dysphonia and laryngotracheal pathology

N. Clayton, P. Kennedy, P. Maitz — 2010-09-01

Abstract: Introduction: Insertion of a tracheostomy for a severe burn patient is not uncommon. The method of decannulation, effects of the tracheostomy on voice and swallowing and subsequent complications have not been described in the literature specifically for this population. The aim of this study was to investigate the risk of dysphagia, dysphonia and laryngotracheal pathology in severe burn patients with tracheostomy and following decannulation.Method: A retrospective chart review was conducted for severe burn patients admitted from January 2000 to December 2007 that received tracheostomy as part of their treatment.Results: Two hundred and thirty patients were admitted during the study period, 26 of whom underwent tracheostomy. Significant positive correlations were identified between tracheostomy duration and %TBSA burn, days to commence oral intake and days to commence pre-morbid oral diet. Several dysphagic features were identified within the oral and pharyngeal phases of swallowing and dysphonia was frequently demonstrated on perceptual voice assessment with the tracheostomy in situ and following decannulation. Laryngotracheal pathology was diagnosed in 12 of the 26 patients (46.2%) whilst the tracheostomy was in place; 2 with laryngeal granulation tissue, 2 with tracheal granulation tissue, 2 with supraglottic oedema and erythema and 6 with reduced vocal mobility.Conclusion: Severe burn patients that have prolonged tracheostomy are likely to have a larger size burn, take longer to commence oral intake and achieve pre-morbid oral diet. These patients are also at risk for dysphagia, dysphonia and laryngotracheal pathology.

Perioperative use of cuffed endotracheal tubes is advantageous in young pediatric burn patients

2010-09-01

Abstract: Uncuffed endotracheal tubes traditionally have been preferred over cuffed endotracheal tubes in young pediatric patients. However, recent evidence in elective pediatric surgical populations suggests otherwise. Because young pediatric burn patients can pose unique airway and ventilation challenges, we reviewed adverse events associated with the perioperative use of cuffed and uncuffed endotracheal tubes. We retrospectively reviewed 327 cases of operating room endotracheal intubation for general anesthesia in burned children 0–10 years of age over a 10-year period. Clinical airway outcomes were compared using multivariable logistic regression, controlling for relevant patient and injury characteristics. Compared to those receiving cuffed tubes, children receiving uncuffed tubes were significantly more likely to demonstrate clinically significant loss of tidal volume (odds ratio 10.62, 95% confidence interval 2.2–50.5) and require immediate reintubation to change tube size/type (odds ratio 5.54, 95% confidence interval 2.1–13.6). No significant differences were noted for rates of post-extubation stridor. Our data suggest that operating room use of uncuffed endotracheal tubes in such patients is associated with increased rates of tidal volume loss and reintubation. Due to the frequent challenge of airway management in this population, strategies should emphasize cuffed endotracheal tube use that is associated with lower rates of airway manipulation.

Burns caused by alcohol-based fires in the household coal stove in Anhui Province, China

Xu-Lin Chen, Feng Guo, Xun Liang, Fei Wang, Yong-Jie Wang, Ye-Xiang Sun — 2010-09-01

Abstract: The Chinese peasants in the middle of Anhui Province and north of Dabieshan Mountain are accustomed to using industrial alcohol to kindle honeycomb briquettes in their household coal stoves. Pouring alcohol into the stove often results in flame burns when the honeycomb briquettes inside are not completely extinguished. The purpose of this study is to describe the unique cause and clinical characteristics of this type of injury.Methods: A retrospective review was performed in the Anhui Medical University Hospital Burn Center during a 10-year period, from January 1998 to December 2007, on the records of patients, who sustained burns by alcohol-based firing in household coal stoves. A total of 180 patients were identified and divided into two groups: children (<14 years of age) and adults (>14 years of age).Results: Boys and housewives were at greatest risk for this burn. As many as 115 patients (64%) sustained more than 10% burns, and children had a significantly larger full-thickness burn area than that of adults. The upper limbs of children and the lower limbs of adults were the most common areas to be injured. All patients came from Shucheng and its neighbouring counties, all of which are located in the middle of Anhui Province and to the north of Dabieshan Mountain. Summer months and daytime, especially during 16:00–17:59h and 8:00–11:59h, were the times of the highest incidence. A total of 80 patients underwent surgical intervention. The mean lengths of stay in hospital of children and adults patients were 21.38 days and 16.96 days, respectively. Two children died of severe shock, leading to a mortality rate of 1.11%.Conclusion: Burns caused by alcohol-based fires in household coal stoves is a common thermal injury in the middle of Anhui Province in China with characteristic clinical presentation and calls for preventive educational intervention.

Procutase® versus 1% silver sulphadiazine in the treatment of minor burns

F.R. Grippaudo, L. Carini, R. Baldini — 2010-09-01

Abstract: The purpose of this randomised comparative study was to evaluate the use of silver sulphadiazine (SSD) 1% cream (Group A) with the use of Procutase® (Group B) in treating burns with a TBSA <10% and a depth not greater than 2nd degree burns and thus suitable for outpatient management. The two groups were similar in age, gender, race, and extent of burn. Procutase® is an ionic hydrogel composed of natural hydrophilic polymers in an active ionic solution with an inhibitor of matrix metalloproteinases MMP-1, -3 and -9 (collagenase/gelatinase). Subjects were seen in follow-up biweekly, and wounds of patients in SSD group were compared with those of Procutase® group for healing time, pain score at dressing change, compliance with therapy and complication rate. The result of this study showed that Procutase® treated patients had statistically significantly less pain and shorter wound healing time. Procutase® can be used successfully in patients with burns that do not require hospital admission.

Dried irradiated human amniotic membrane as a biological dressing for facial burns—A 7-year case series

E. Bujang-Safawi, A.S. Halim, T.L. Khoo, A.A. Dorai — 2010-09-01

Abstract: Background: Facial burns are common and have a significant impact on patient function and psychosocial well being. Human amnion has been used for many years as a temporary biological wound dressing in the management of partial thickness burns. The observed advantages of human amnion treatment include pain relief, ease of use, prevention of infection and acceleration of wound healing.Objective: This study evaluated our 7 years of working with dried irradiated human amnion in the treatment of facial burns.Method: A review of patients, treated with dried human amnion for facial burns between 2001 and 2008. Demographic details collected included age, gender, total facial surface area burned, type of burn and cause of injury. The effectiveness of the treatment was determined by wound infection rate, frequency of dressing reapplication, healing time and resulting scarring.Results: Thirty-three patients with superficial partial thickness burn were identified (25 males, 8 females). The average age of the patients was 16.5 years (range: 8 months to 64 years). The causes included scalding (n=15), contact burning (n=13) and flash burning (n=5). The mean percent total facial surface area burned was 2.7% (range: 0.5–8.5%). None of the patients developed facial wound infections. Eighty-five percent (n=28) of the patients needed a single application of the dried amnion. The average healing time was 5.4 days (range: 2–14 days). Thirteen patients (39%) had burns confined to the facial area, of which three were discharged and treated as outpatients. Long-term follow up showed two hypopigmented scars, one hyperpigmented scar and one hypertrophic scar.Conclusion: Superficial partial thickness facial burns can be effectively treated with dried irradiated human amnion membrane.

Absence of pathological scarring in the donor site of the scalp in burns: An analysis of 295 cases

2010-09-01

Abstract: Aim: This study aims to describe the incidence of complications on scalp from which a thin split-skin graft was harvested (0.005–0.007in.) of the donor site in children and adult burn victims.Methods: We reviewed the medical records of 295 burn patients admitted in the Burn Unit of the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto, from January 1998 to December 2007, whose scalps were used as donor site for grafts. Skin-graft thickness varied from 0.005in. to 0.007in. The occurrence of pathological healing was evaluated clinically and the time of epithelisation by the main surgeon and a plastic surgeon or a staff nurse.Results: Of the 295 patients whose scalps were used as donor site, 274 were followed from 6 months to 10 years after the procedure (median 18.2 months). Twenty-one patients were lost to follow-up in the first 6 months. No hypertrophic scarring or keloids on the donor site was observed. Five patients (1.82%) presented with folliculitis and two of them were evaluated with small areas of alopecia (0.7%), treated with resection of these areas and primary suture. The average time of epithelisation of the donor site was 7 days.Conclusion: The harvest of thinner split graft from the scalp is a safe procedure.

Evaluation of a new type of wound dressing made from recombinant spider silk protein using rat models

Lu Baoyong, Zheng Jian, Chen Denglong, Li Min — 2010-09-01

Abstract: This study investigates the feasibility of recombinant spider silk protein as a wound-dressing material for coverage of deep second-degree burn wounds using an animal model. Sixty Sprague–Dawley (SD) rats were randomly divided into four groups (15 rats in each group). Two types of recombinant spider silk proteins, pNSR-16 and pNSR-32, as well as collagen (as a control) were applied on the wound; the fourth group was left untreated as a negative control. Each group was evaluated on the 3rd, 5th, 7th, 14th and 21st days for wound-healing rate, histological test, levels of hydroxyproline synthesis and the samples were stained for immunohistochemical detection of the basic fibroblast growth factor (bFGF). The results of implantation testing showed that wound healing in the treatment groups – recombinant spider silk protein pNSR-16 and pNSR-32 – was much better than that in the control group (p<0.01). On the 7th, 14th and 21st days, higher expression of bFGF and the increase of hydroxyproline content of the skin indicated good regeneration of wound skin in the treatment groups. Preliminarily, we conclude that the recombinant spider silk protein membrane promotes the recovery of wound skin by increasing the expression and secretion of the growth factor bFGF and hydroxyproline.

The application of glycerol-preserved skin allograft in the treatment of burn injuries: An analysis based on indications

T.L. Khoo, A.S. Halim, A.Z. Mat Saad, A.A. Dorai — 2010-09-01

Abstract: Introduction: Glycerol-preserved skin allograft (GPA) plays a crucial role in the management of burns. Its indications include wound-bed preparation, definitive dressing and sandwich grafting technique.Objective: We analysed the experience of using GPA and its efficacy in burn treatment in our burn centre.Methods: All burns managed with GPA in our burn centre from October 2001 to May 2008 were analysed.Results: Mean total body surface area (TBSA) of 43 consecutive cases was 28.7%. GPA adhered to the wound for an average of 8.4 days before rejection. The length of hospital stay of the survivors was 42.5 days. The autograft take after wound-bed preparation with GPA was 88.4%. For sandwich grafting technique, the autograft take was 74.4%. When GPA was applied for partial-thickness burn as definitive dressing, all patients achieved complete healing within an average of 19 days without further surgical intervention. Despite colonisation of burn wounds after application of skin allograft, the outcomes of autograft take and wound healing were not significantly different.Conclusion: The selective and strategic use of the GPA in major burn patients ensures optimal benefits in the management of burns. It is versatile in various categories of burn wounds with minimal morbidity.

Muscle contractile properties in severely burned rats

Xiaowu Wu, Steven E. Wolf, Thomas J. Walters — 2010-09-01

Abstract: Burn induces a sustained catabolic response which causes massive loss of muscle mass after injury. A better understanding of the dynamics of muscle wasting and its impact on muscle function is necessary for the development of effective treatments. Male Sprague–Dawley rats underwent either a 40% total body surface area (TBSA) scald burn or sham burn, and were further assigned to subgroups at four time points after injury (days 3, 7, 14 and 21). In situ isometric contractile properties were measured including twitch tension (Pt), tetanic tension (Po) and fatigue properties. Body weight decreased in burn and sham groups through day 3, however, body weight in the sham groups recovered and increased over time compared to burned groups, which progressively decreased until day 21 after injury. Significant differences in muscle wet weight and protein weight were found between sham and burn. Significant differences in muscle contractile properties were found at day 14 with lower absolute Po as well as specific Po in burned rats compared to sham. After burn, the muscle twitch tension was significantly higher than the sham at day 21. No significant difference in fatigue properties was found between the groups. This study demonstrates dynamics of muscle atrophy and muscle contractile properties after severe burn; this understanding will aid in the development of approaches designed to reduce the rate and extent of burn induced muscle loss and function.

Hospitalised hot tap water scald patients following the introduction of regulations in NSW, Australia: Who have we missed?

2010-09-01

Abstract: Scalds from hot tap water are serious injuries that are potentially preventable by restricting the temperature of hot tap water delivery. In July 1999, regulations were introduced in NSW to require that all new hot water installations deliver water at temperatures not exceeding 50°C to sanitary fixtures. This study investigates trends in hot tap water scald injury hospitalisations following the introduction of these regulations.Hot tap water scald cases for 1999–2007 were identified from hospitalisation data for all public and private hospitals in NSW. To investigate hot tap water scald hospitalisations over time, negative binomial regression analysis was performed.There were 845 hospitalisations for hot tap water scalds in NSW over the period of the study. Hospital admission rates for hot tap water scalds decreased by an estimated 6% (3.2–8.5, 95%CI) per year since the introduction of regulations. While those most at risk were infants, toddlers and the elderly, almost a third of hospitalisations were for adults (25–64 years). The majority of hot tap water scalds were sustained at home and a further 4% occurred in a residential institute or school. The majority of scalds were severe, and a quarter required admission for longer than a week.The introduction of regulations in NSW appears to have had a positive impact on the rates of hospitalisations for hot tap water scalds; however, scalds continue to cause significant morbidity and mortality. This highlights the need for a review of the scope and implementation of the existing regulations and ongoing education of the general public to the dangers of hot tap water.

Burns related to sunbed use

S.J. Hemington-Gorse, M.A. Slattery, P.J. Drew — 2010-09-01

Abstract: The quest for a year round tan has led to an increase in the use of artificial tanning devices, namely sunbeds. There has been much debate in the press recently regarding the dangers of sunbed use and calls for tighter regulation of the industry, particularly the licensing of unmanned tanning salons. The dangers of sunbed use have long been recognised and the body of evidence linking sunbed use to skin malignancy is growing, in fact this month the Lancet published a review from the International Agency for Research on Cancer classifying UV emitting tanning devices as carcinogenic to humans. At the Welsh Centre for Burns and Plastic Surgery we noticed a rise in the number of patients presenting with burns related to sunbed use and present our data surrounding this injury over the last 6 years.

Chemical assault and skin/eye burns: Two representative cases, report from the Acid Survivors Foundation, and literature review

Rebecca Milton, Laurence Mathieu, Alan H. Hall, Howard I. Maibach — 2010-09-01

Abstract: Chemical assault is a significant problem throughout the world, resulting in disfigurement, sometime blindness or vision impairment, and constituting a major economic burden on otherwise overwhelmed health services in developing countries. Two representative cases are presented here. One involved domestic spouse abuse with an acid and the second involved a teen-aged female assaulted with an acid, perhaps for retribution over a local judicial matter. Such atrocities have a world-wide scope, which is reviewed here. Preventive measures are the most appropriate response. However, when such chemical assaults do occur, active measures to mitigate or negate their effects deserve consideration.

Epidemiology of minor and moderate burns in rural Ardabil, Iran

2010-09-01

Abstract: Epidemiology of minor burns is not well defined worldwide. The aim of this study was to examine epidemiological features of minor and moderate burn events that could be beneficial for prevention purposes. The study was conducted in Ardabil province in north-west Iran in 2005–2006. A total of 1700 minor and moderate burns were studied using a pretested questionnaire. Using the SAS 9.1 statistical program analyses were made. Females comprised the majority of cases (n=1000, 58.8%) and children, aged six and younger, made up 36.4% of burn victims. The majority of burns were caused by hot water and tea with the primary containers being kettles in 37.8%, cups or glasses in 24.2%, pots in 13.6% and samovars in 7.9%. Samovars, gas stoves, valors and picnic gas stoves were the primary heating devices involved in burns. In 56% of the cases, overturning of liquid containers was the primary injury mechanism of scalds. 43% had a second-degree burn with a mean total body surface area of 1.3%. This study provides possible beneficial information for burn prevention in the Ardabil area and other similar settings.

The increasing trend in alcohol-related burns: It's impact on a tertiary burn centre

William J.M. Holmes, Phoebe Hold, Malcolm I. James — 2010-09-01

Abstract: Introduction: The incidence of alcohol-related hospital admissions is a worldwide problem and currently costs the UK National Health Service approximately 4% of its annual budget. 40% of men and 22% of women drink over the recommended UK weekly allowance. The purpose of our study was to examine the trend in alcohol-related admissions to a tertiary burns unit over a 5-year period.Methodology: All patients admitted were documented for alcohol-related burn, and history of alcohol dependence.Results: 1293 patients admitted between 2003 and 2008 were included in the study. The number of alcohol-related burns were as follows: 2003: 6%; 2004: 10%; 2005: 16%; 2006: 9%; 2007: 19%; 2008: 19%. This increasing trend was highly significant (p<0.0001). Alcohol-related burns had a higher incidence of flame injury (60%) and a subsequent longer length of stay (12.5 vs. 7.9, p=0.04). Alcohol dependence was noted in 54% of all alcohol-related burns and in 5% of the non-alcohol-related burns.Discussion: The number of alcohol-related burns admitted to a tertiary burn unit is increasing and now comprises of nearly 20% of all admissions. This highlights the growing burden of alcohol on health and the need to address it at both a national and regional level.

Three cases of inner ear damage after electrical burns

2010-09-01

Electrical injury is a significant cause of mortality and morbidity, accounting for 1000 deaths per year and a far greater number of injuries . Electrical burns produce a spectrum of tissue injuries that range from obvious thermal destruction of tissue to the gradual onset of neurological defects even in the absence of apparent thermal injury. In spite of the ever increasing awareness and precautionary measures in both work and leisure environments, electrical injuries unfortunately are still happening. Until now, the exact pathophysiology of different types of burn along with electric trauma remains controversial due to different modalities depending on types and patterns of injuries .

Adult respiratory distress syndrome or congestive heart failure in severe burn: A role for brain natriuretic peptide

2010-09-01

In patients with extensive burns several causes may underlie hypoxic respiratory failure and bilateral infiltrates on the chest X-ray in the first week afterburn: cardiogenic pulmonary edema as a result of congestive heart failure, pneumonia and/or adult respiratory distress syndrome (ARDS). In particular, it is a challenge to differentiate between ARDS and cardiogenic pulmonary edema in these patients because on the one hand the incidence of ARDS in burn shock appears higher than anticipated, whereas on the other hand there is an increased risk for cardiogenic pulmonary edema to develop as intensive fluid resuscitation is mandatory, while myocardial function is depressed as noted by Baxter et al. . Since these two diagnoses have very different treatment options, it is important to be able to differentiate between them as soon as possible.

Two case reports: Electrothermal (aka contact) burns and the effects of current density, application time and skin resistance

B.D. Barkana, N. Gupta, L.V. Hmurcik — 2010-09-01

It is well known that an electric shock may cause death or some degree of burn damage to organs and body systems; the severity of the injury is dependent on many variables: type of current, level of applied voltage, duration of shock, body contact surface area, resistivity of skin involved, contact with water or metal conductor and current pathways through the body .

A fatal case of toxic shock syndrome associated with skin substitute

2010-09-01

The association of staphylococcus aureus with a syndrome called toxic shock syndrome (TSS) was made in 1978, although cases of patients with similar findings had been reported as far back as 1927 . The syndrome was characterised by: a high fever, headache, confusion, conjunctival hyperaemia, a scarlatiniform rash, subcutaneous oedema, vomiting, watery diarrhoea, oliguria, and a propensity to acute renal failure, hepatic abnormalities, disseminated intravascular coagulation, and severe prolonged shock. These findings were described in seven children. From five of these, phage-group-1 staphylococci were isolated. Interestingly the four girls included in the series may have been using tampons, no link was made with this at the time.

Practical management of the burnt patient with epidermolysis bullosa

D.D. Atherton, A. Latif, G. Williams — 2010-09-01

Epidermolysis bullosa (EB) is a group of inherited bullous disorders characterised by blister formation in response to mechanical trauma. Care of burns patients with this disease can be difficult, in particular with respect to healing of the skin graft donor sites. A number of techniques, such as laying of the sheared epidermis as a graft, can help speed up healing time.

Mentosternal contracture treated with a massively expanded supraclavicular flap in a 25-year-old man: A case report

Abdoljalil Kalantar Hormozi, Mohammad Reza Shafii — 2010-09-01

Tissue expansion has become a major reconstructive modality in the past 30 years. Tissue expansion is a major treatment modality in the management of giant congenital nevi and secondary reconstruction of extensive burn scars, allowing sensate tissue of similar color, texture, and thickness to be used to resurface the affected areas. One must be prepared for complications when using tissue expanders, however, because complications are inherent in the process of expanding skin utilizing repeated filling of implanted foreign bodies . Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. The cervical region is functionally and anatomically designed to achieve a maximum range in three-dimensional motion. Furthermore, the cervical area, as does the facial region, functions as a medium to interact with human society. For the unfortunate patients who develop scar contracture, resurfacing with flaps offers an optimal reconstructive outcome. The emphasis, therefore, has been on the use of various flap reconstructions, which have mirrored the historical understanding of the blood supply to the skin .

Secondary sclerosing cholangitis, following major burn injury

Sammy Al-Benna, Jörg Willert, Hans-Ulrich Steinau, Lars Steinstraesser — 2010-09-01

Sclerosing cholangitis represents a spectrum of variably progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system that can develop following a wide range of insults to the biliary tree . It is characterised by a progressive destruction of the intra- and extrahepatic biliary tree with inflammation, obliterative hepatic and biliary fibrosis, stricture formation that leads to biliary cirrhosis .

Unusual first presentation of metastatic pancreatic cancer as skin metastases in a burn patient

Alexander C.J. van Akkooi, Jan Dokter, Han Boxma — 2010-09-01

Pancreatic cancer is one of top 5 causes of cancer related deaths in the Netherlands, but also in the U.S.A. and other Western European countries . In 2006, there were 2126 deaths due to pancreatic cancer in the Netherlands , on an estimated population of 16,500,000 people, this equals 0.1288 deaths per 1000 people. Due to the lack of early symptoms, most patients present with advanced disease and therefore only approximately 15–20% of patients can be considered as candidate for a pancreatectomy according to Whipple. The 5-year overall survival rates of study populations after Whipple's operations have been reported to be 25–30% for node negative and 5–10% for node positive patients .

Management of second-degree burn induced by dry ice in a Christmas disease patient

A. Troccola, M. Maruccia, A.E. Zampieri, L.A. Dessy — 2010-09-01

Christmas disease (also named haemophilia B) is a blood clotting disorder caused by a mutation of the Factor IX gene, leading to a deficiency of Factor IX. It is the least common form of haemophilia, rarer than haemophilia A. It is also called ‘Christmas disease’ because Stephen Christmas was the first patient described with this disease. In addition, the first report of its identification was published in the Christmas edition of the British Medical Journal .

The role of an ingestible telemetric thermometer in preventing exertional heat stroke, for a patient with healed massive burns running the 2007 London marathon

Ryckie G. Wade, Peter Dziewulski, Bruce M. Philp — 2010-09-01

Adequate thermoregulation relies upon an intact dermis and epidermis . Cutaneous vessels dilate to dissipate heat (“dry heat loss” via conduction, convection and radiation) and constrict in order to retain heat. Dermal sweat glands are vital adnexal structures required for heat loss during exercise via evaporation (“wet heat loss”). It is generally believed that extensive thermal damage to the integumentary system impairs thermoregulation for a variety of reasons.

Comments on “Platelet-rich plasma in burns”

2010-09-01

Authors’ should be congratulated for the review article “Platelet-rich plasma in burns” by Pallua et al. , which is exhaustive and clear. With the present communication, we would like to add a few considerations based on ours and other most recent experience.

Authors reply on the comment to “Platelet rich Plasma in burns” by Curinga et al

Timm P. Wolter, Norbert Pallua — 2010-09-01

Thank you for the comment on our article and the emphasis on the changes and effects of burn on the platelets itself. We agree with your statement that the increasing number of bedside kits available is somewhat irritating since they often do not explain the physiological impact.

Apparent high chloraemia in persons with deep third-degree burns: Interference linked to topical treatment

2010-09-01

In recent years, we observed cases of abnormally high chloraemia in some patients hospitalised at the Burn Treatment Center, which are not consistent with the remaining aspects of the patient's hydro-electrolytic equilibrium. Disagreements are also observed between chloraemia measured by direct total arterial blood potentiometry (ABL™ 700, Radiometer™ blood gas analyser) and those measured by indirect potentiometry on plasmatic samples (Cobas Integra 800™, Roche Diagnostics).

Survival area of super-thin flaps

Rei Ogawa, Hiko Hyakusoku — 2010-09-01

We would like to make some comments on a letter written by Dr. Prakash entitled “The pedicled super-thin flap for resurfacing defects due to burn” . Based on their past clinical experience with pedicled super-thin flaps, Dr. Prakash states in his letter that “Hyakusoku et al. failed to offer a rationale for the length and breadth of the flap that could be super-thinned”, and concluded that “it should be raised in a length:breadth ratio of 1:1 and the rest of the length of flap should not be thinned”. We believe that these comments show a lack of knowledge and understanding of our flaps.

Patient controlled sedation using a standard protocol for dressing changes in burns: Patients’ preference, procedural details and a preliminary safety evaluation. Are studies always adequately powered and analyzed?

A. Mangano, A. Albertin, L. La Colla — 2010-09-01

We read with interest the article published by Dr. Nilsson and colleagues . While the authors are to be commended for their aim to conduct a preliminary study to evaluate different sedation protocols during dress change in burned patients, there are several issues with both the design of the study and the statistical analysis used.

Patient controlled sedation using a standard protocol for dressing changes in burns: Patients’ preference, procedural details and a preliminary safety evaluation. Are studies always adequately powered and analyzed?

Andreas Nilsson, Ingrid Steinvall, Zoltan Bak, Folke Sjöberg — 2010-09-01

We are very pleased for the interest shown by Dr. Mangano and co-workers in our publication “Patient controlled sedation using a standard protocol for dressing changes in burns: Patients’ preference, procedural details and a preliminary safety evaluation” . We understand the scientific concern to have sufficiently powered studies in clinical as well as experimental studies. However, in the present context, in the early development phase of a clinical project like ours, such an aim, as suggested by Dr. Mangano et al. is both extensively costly, impractical and technically impossible to conduct. The reasons will be listed below.

Severe burn injuries sustained whilst under inpatient psychiatric care—A worrying trend

E.C. Toll, F. Salim, D. Izadi, T.S. Burge — 2010-09-01

We have been concerned by a recent increasing trend that we have observed in the number of cases of self-inflicted burns in patients detained under section 3 of the UK Mental Health Act (2007).