Advances in Paediatric Burn Management. Bernard Carney Burns Unit Women s and Children s Hospital

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1 Advances in Paediatric Burn Management Bernard Carney Burns Unit Women s and Children s Hospital

2 WCH Paediatric burns service Women s and Children s Hospital 0 to 18 years of age inpatients outpatients/year. Nursed in the Burns/plastics/surgical ward (Newland Ward) Daily outpatient burns clinic plus 24 hour emergency dressing advice Digital Referral Service Guidelines on the internet Digital photos can be sent to childrensburns.sa.gov.au

3 Burns Multi D team > Surgical Consultants General and Plastics > Burns Advanced Clinical Practice Consultant > Newland ward Nurses > Burns Registrar > Burns Fellow > Burns RMO > Social Worker > Dietician > Physiotherapist > Occupational Therapist > Psychiatrist > Anaesthetist > Pharmacist

4 Referral to a burn service Burns > 5% TBSA Burns to the face, feet, genitalia, perineum, major joints. Electrical burns Chemical burns Inhalation burns Circumferential burns Burn injury in patients with pre-existing medical disorders Burns with associated trauma Non-accidental burns And any patient you are not happy to treat

5 Burns in Children The causes, assessment and management of Paediatric burns are different to that of adults... The size and body proportions of the child The thickness of the skin The different social and emotional development of children.

6 Causes: Adults vs Children > Explosion/ flame 48% > Scalds 33% > Contact 8% > Electrical 5% > Chemical 3% > Friction 2% > Sunburn 1% > Scalds 60% > Flame 25% > Contact 10% > Electrical 2% > Chemical 2% > Sunburn 1%

7 Pathophysiology o Heat applied to the skin causes Denaturation of proteins Loss of plasma membrane integrity o Necrosis occurs at the centre of the injury and becomes less severe at the periphery

8 Pathophysiology > Zone of coagulation centre of wound where no viable cells remain > Zone of stasis characterised by a mix of viable and non-viable cells, capillary vasoconstriction and ischemia > Zone of hyperemia - - characterised by viable cells and vasodilation caused by local inflammatory mediators

9 Burn Depth o Epidermal o Dermal o Superficial o Mid o Deep o Full thickness

10 Burn Depth Depth Colour Blisters Capillary Refill Sensation Epidermal Red No Present Present Superficial Dermal Mid-dermal Pale pink Dark pink Small and thin walled Present Present Large Sluggish Reduced Deep dermal Full thickness White or blotchy red White or brown May or may not be present Absent Absent No Absent Absent

11 Epidermal Depth Colour Blisters Capillary Refill Sensation Epidermal Red No Present Present

12 Epidermal Burns o Mechanism of healing o Re-epithelialization from the basal layer of the epidermis o Time to heal o 3-7 days o Scarring o None o Management o Analgesia o Moisturizer o Hypafix

13 Superficial Dermal Depth Colour Blisters Capillary Refill Superficial Dermal Pale pink Small and thin walled Present Sensation Present

14 Mid-dermal Depth Colour Blisters Capillary Refill Mid-dermal Dark pink Sensation Large Sluggish Reduced

15 Deep Dermal Depth Colour Blisters Capillary Refill Deep dermal White or blotchy red May or may not be present Absent Sensation Absent

16 Dermal Burns o o o o Mechanism of healing o Re-epithelialization from dermal adnexal structures Time to heal o Superficial partial thickness o 7-10 days o Deep dermal partial thickness o days Scarring o Related to burn depth and time to heal o Superficial dermal o Not usually o Deep dermal o Common Management o Removal of dirt and devitalised tissue o Dressings o Deep dermal burns treated with trial of life

17 Full Thickness Depth Colour Blisters Capillary Refill Full thickness White or brown Sensation No Absent Absent

18 Full Thickness Burns o Mechanism of healing o Contraction and reepithelialization at the edges o Time to heal o Weeks to months (size dependent) o Scarring o Yes o Management o Surgical management

19 Dressings Acticoat Antimicrobial Acticoat, Mepilex Ag, Aquacel Ag, Flamazine, chloromycetin ointment Non-Antimicrobial Jelonet, soft white paraffin, Duoderm Glad wrap for short distance transfer Mepilex Ag

20 Advances in Burn Management > History > Skin substitutes > Cultured keratinocytes > Burn referral and assessment > Emergency management of severe burns > Scar management > Education- children and population > Maintenance of growth

21 Milestones of burn management so far > McIndoe and the Guinea Pig Club > Cocoanut Grove disaster > Early debridement and tangential excision > Skin Substitutes

22 Cocoanut Grove Disaster > Nov 28, Killed > Francis Daniel Moore and Oliver Cope, Massachusetts General. 200 patients admitted > Significant new therapies: Dressed not tanned Fluid resusucitation Use of blood products Use of penicillin

23 The Guinea Pig Club > Formed 1941, East Grinstead > Archibald McIndoe > Burned airmen, mainly face and hands > Advanced reconstructive techniques > Rapid spread of techniques through Allied countries

24 Jancekovic, 1970 > Early debridement of burns and immediate grafting > Tangential excision Quicker recovery Better quality scar Improved morbidity and mortality

25 Current Advancements > Skin substitutes > Education > Information technology > Medical technology > Hypermetabolic therapy

26 Skin Substitutes > Temporary or permanent > Biological or non biological > Xenograft (different species-porcine) > Allograft (different individual- cadaver) > Isograft (genetically identical graft) > Autograft

27 Tempoary Skin Subsitutes > Simple dressings: Glad wrap, opsite, DuoDERM > Biobrane > TransCyte

28 Biobrane > Silicon/nylon mesh with porcine collagen > Allows adhesion > Functions as a temporary epidermis > Comfort and ease of use

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31 Permanent Skin Substitutes > Integra > Apligraf > Dermagraf > Cultured epitheial autograft

32 Integra > Bovine collagen/shark chondroitin sulfate > Outer silicon layer > Creates neodermis with vascular ingrowth > Silicon provides epidermal cover

33 Integra Intra-operatively Integra 7days post application Healed Meshed 3:1 SSG over Integra Application of very thin meshed autograft 14+ days the silicone layer is removed Healed Meshed 3:1 SSG (no Integra )

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35 Loss of Integra Due to infection Infected Integra Note: Yellow pus and areas of collection under Integra How Integra should look Type of burn suitable for Integra Full thickness thermal injury

36 Full thickness facial burn prior to Integra placement Integra - Intraoperatively Graft following Integra removal Successful outcome post Integra treatment

37 Cultured Epithelial Autograft > In use since 1990s > Keratinocytes easy to grow, difficult to apply > Sheet keratinocyte culture Harder to grow and apply Fragile in situ- shear and blister > Keratinocytes in suspension Popularized by Fiona Wood Allow vast quantities of cells to be grown Sprayed on Adjunct with other methods

38 Education: Emergency Management of Severe Burns > Australian developed course > ANZBA early 1990s > Framework for education and management > Standardized treatment Australia wide > Increased level of care through both tertiary and primary care centres > Nurses, doctors, paramedics etc

39 Education: Wider Community > Legislation and standards > Julian Burton Burns Trust Education in schools Nursing scholarships Education of burns survivors

40 IT and Burns > Burns Registry > Digital referral service > Allow improvement in service delivery and standardization of care

41 Burns Registry of Australia and New Zealand (BRANZ) > Adult and paediatric units > Submission of data by units on various parameters- standardized audit > Quarterly report > Comparative data given on a number of areas Primary cause ICU stays Theatre management Inhalation unjury %TBSA

42 Burns Digital Referral Service

43 How and why did we start? Medical Records + IT Services + Digital media + Burns clinicians

44 So how does it work? Phone call Web based referral Treatment advice Documentation & Image storage

45 Referral Service Audit Results Service benefits: 80% referrals would have otherwise been transferred to Adelaide Enables and empowers local delivery of patient care Cost saving

46 Cost savings Air ambulance costs e.g. remote community to WCH = $25,000 - $30,000 Parental loss of work Family disruption Accommodation costs

47 Referral Service Audit Results Needs identified: More promotion of the Burns Referral Service More burns education in catchment area centres

48 Referral Service Audit Results Parent/Guardian benefits: Local access to care with specialist input Less travel Less time off work Less disruption to the whole family

49 Challenges Referrals Transient rural health staff Photo consent Photo quality Have you seen this boy? Can you see the burn?

50 Burns Digital Referral Service > to > Call the WCH and ask for the Burns Advanced CPC or Burns Fellow during hours > Call the WCH and ask for the on call Surgical registrar out of hours

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52 Hypermetabolism in Burns > Limitation of energy expenditure early and conversion of catabolic state to anabolic reduces mortality and early and late morbidity > Long term studies from Shriners institues in the States- David Herndon > Multiple therapies directed towards this: Early excision and wound closure Early feeding Early exercise

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54 Key principles > Early excision and coverage of burn Energy expenditure 40% less in those with excision of burns within 72 hours compared with 1 week > Appropriate caloric intake High carbohydrate and high protein diet to limit catabolism > Ambient warming of patient Some energy is expended counteracting heat loss from burns eschar, hypothalamic resetting sees core body temperature raise by 2 degrees Having room warmed to 33 degrees offsets this energy loss as it is at this point the energy for evaporation is derived from the environment. A 33 degree room will reduce the magnitude of hypermetabolic response from 2.0 to 1.4 the REE in a burn >40%. > Pharmacologic therapies to assist in protein anabolism and maintenance of lean body mass, muscle mass and bone density

55 Propanolol Propranolol: Non-selective B-blocker. Blocking of adrenaline and noradrenaline at both B1 and B2 receptors. Benefit through amelioration of catecholamine surge in burns patients. Aim: Decrease cardiac work (RPP and REE). Decrease heart rate by greater than 15% Decrease truncal fat accumulation, liver steatosis and increase lean body mass. Increase speed of donor site healing No effect on PTSD or anxiety post burn proven

56 Administration: > Escalation of dose 1mg/kg/day to 4mg/kg/day to achieve a decrease in heart rate of 15-20%. Treatment to be given for 12 months > Rate: Daily dose divided into 4, given six hourly. > ICU continuous monitoring initially > Hold or decrease dose when mean blood pressure (MBP) less than 65mmHg.

57 Long term: > Long term follow up to check growth velocities Height / weight / BMI / lean body mass

58 OXANDROLONE

59 Oxandrolone > Oxandrolone, a synthetic analogue of testosterone, has minimal virilizing activity (5%) and low hepatotoxicity compared with testosterone. > In skeletal muscle, oxandrolone binds to the androgen receptor and migrates to the cell nucleus, where it stimulates protein synthesis and anabolism. > It also exerts its anabolic effects by counteracting the catabolic effects of cortisol through competitive inhibition of the glucocorticoid receptors. > Effects both muscle mass / strength as well as being osteoprotective (likely through paracrine mechanisms not fully understood)

60 OXANDROLONE > It has been used to induce anabolism in patients experiencing muscle wasting associated with AIDS, major surgery, infections, malnutrition, neuromuscular disorders, or thermal injury. > Short-term oxandrolone use is associated with a lack of normal reduction in liver enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT) from 17 to 40 days post burn (effective increase) > The addition of exercise programs with the use of oxandrolone in burnt children further potentiates is anabolic benefits.

61 > Post-burn catabolic effects are not limited to muscle, as bone mineral content (BMC) and fat mass are decreased as well. > This hypermetabolic response persists for up to 2 years after burn injury, greatly reducing quality of life for severely burned patient

62 PAMIDRONATE

63 Pamidronate > Mimics naturally occurring compound pyrophosphate in bone > Potent inhibitor of osteoclast activity > Safe in children (Long term use in Osteogenesis Imperfecta) > Bone loss in burns is a complex interaction between increased endogenous glucocorticoid production resulting from the stress response Resporptive cytokine release resulting from the systemic inflammatory response Progressive vitamin D deficiency

64 How much bone loss? > Manifested by an approximate 2% loss of total body bone mineral content (BMC) by 2 months post burn, increasing to about 3.5% by 6 months, with lumbar spine BMC falling by about 8% by 2 months post burn and remaining stable at this level at 6 months.

65 On the Horizon > Quantifying and improving education delivery to long term patients > Fractionated CO2 laser Increase pliability and softness of scar minimal wound care comfort Day procedure

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