STRC CTANZ

Surgical Trainee Research Collaboratives in Australasi

Adequacy of cool running water first aid by healthcare professionals in the treatment of paediatric burns : A cross-sectional study of 4537 children

Objective: To determine the adequacy of cool running water first aid provided by healthcare professionals in the early management of children with thermal burn injuries. Methods: A cross-sectional study was undertaken using a prospectively collected registry of children who presented with a thermal burn to the only major paediatric burns centre in Queensland, Australia, from January 2013 to December 2018. Main outcome measures included the type and duration of first aid administered by paramedics, general practitioners and emergency providers at local general hospitals and a children's hospital. In accordance with current Australian guidelines, adequate cooling was defined as 20 min of cool running water within 3 h of the injury. Results: Of the 4537 children who presented to the paediatric burns centre, 3261 (71.9%) received adequate first aid, including 1502 (33.1%) at the scene of injury. Paramedics and general practitioners administered adequate cooling to 184 (25.0%) and 52 (24.2%) of their patients, respectively. ED clinicians adhered to guidelines in the treatment of 1019 (56.3%) children at general hospitals and 411 (76.0%) at the children's hospital. Among ED patients who presented with incomplete prior first aid, the risk of inadequate cooling was significantly greater for those transported via ambulance (P < 0.001). Conclusion: Deficiencies remain in the cooling of paediatric burns patients at all levels of initial management. There is a need in the healthcare community for improved education regarding the parameters and clinical benefits of cool running water first aid.</p

Barriers to adequate first aid for paediatric burns at the scene of the injury

Issue Addressed The recommended first aid for burns, consisting of 20 minutes of cool running water (CRW) delivered within three hours of the injury, offers a simple yet effective means of improving health outcomes. The aim of this study was to determine patient and injury characteristics associated with inadequate CRW therapy among children with thermal burns, with the goal of identifying populations at greatest risk of undertreatment. Methods A cross‐sectional study was performed on children treated at a large tertiary paediatric burns centre. First aid was evaluated as either “adequate” or “inadequate”, and then descriptive analyses were conducted to examine differences between the groups in age, ethnicity, location and socioeconomic status, among others. Results From 2013 to 2016, the families of 2522 patients were interviewed. Overall, 31.3% of children received adequate CRW at the scene of the injury. Provision of adequate CRW did not significantly differ with sex, ethnicity or nationality. Factors that were associated with inadequate first aid included very young age and early adolescence (P Conclusions Although most burns occurred in close proximity to sources of CRW, first aid was poor across all demographics. The highest levels of undertreatment were found in children aged 0‐2, adolescents aged 15‐16, those living rurally or remotely, and the socioeconomically disadvantaged. So what? The study highlights the need for improved public education of first aid for burn injuries

Barriers to adequate first aid for paediatric burns at the scene of the injury

Issue Addressed: The recommended first aid for burns, consisting of 20minutes of cool running water (CRW) delivered within threehours of the injury, offers a simple yet effective means of improving health outcomes. The aim of this study was to determine patient and injury characteristics associated with inadequate CRW therapy among children with thermal burns, with the goal of identifying populations at greatest risk of undertreatment. Methods: A cross-sectional study was performed on children treated at a large tertiary paediatric burns centre. First aid was evaluated as either adequate or inadequate, and then descriptive analyses were conducted to examine differences between the groups in age, ethnicity, location and socioeconomic status, among others. Results: From 2013 to 2016, the families of 2522 patients were interviewed. Overall, 31.3% of children received adequate CRW at the scene of the injury. Provision of adequate CRW did not significantly differ with sex, ethnicity or nationality. Factors that were associated with inadequate first aid included very young age and early adolescence (P<0.001), rural or remote location (P=0.045), low socioeconomic status (P=0.030), radiant heat and flame burns (P<0.001), as well as burns occurring at recreational sites, on farm/trade/industrial properties and in the street (P=0.001). Conclusions: Although most burns occurred in close proximity to sources of CRW, first aid was poor across all demographics. The highest levels of undertreatment were found in children aged 0-2, adolescents aged 15-16, those living rurally or remotely, and the socioeconomically disadvantaged. So what? The study highlights the need for improved public education of first aid for burn injuries

A pilot study comparing two burn wound stereophotogrammetry systems in a paediatric population

Background: Stereophotogrammetry (SPG) provides a more objective measurement of burn wound area than traditional clinical assessments. The recently developed Intel® RealSense™ D415/Wound Measure SPG system has yet to undergo formal evaluation in a paediatric population. Methods: A pilot study comparing the Intel® RealSense™ D415/Wound Measure to the previously validated LifeVizII®/DermaPix® SPG system, for burn assessment was conducted at a tertiary paediatric burn centre. Both systems were used to photograph and analyse the same acute wounds for each patient. Three independent raters measured wound area and perimeter. Level of agreement between systems and raters was estimated by calculating the intra-class correlation coefficient. Results: Wound area measurements were completed in both systems for 25 burns from 13 patients (median age, 2 years). The participants were mainly female (n = 9), with a median TBSA-B of 9% (IQR 3–20%). There was strong agreement between the systems 0.757 (95% CI 0.521, 0.885, p < 0.001). Within each SPG system, there was excellent inter-rater reliability. Conclusion: The Intel® RealSense™ D415/Wound Measure system may be a viable addition to the clinician's toolkit in the assessment of paediatric burn wound area. As with other SPG systems, there were significant challenges measuring wounds to highly contoured surfaces.</p

Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial

Negative pressure wound therapy (NPWT) has been shown to improve clinical outcomes for children with burns by accelerating wound re-epithelialisation. Its effects on healthcare costs, however, remain poorly understood. The aim of this study was to evaluate the cost-effectiveness of NPWT from a healthcare provider perspective using evidence from the SONATA in C randomised controlled trial, in which 101 children with small-area burns were allocated to either standard care (silver-impregnated dressings) or standard care in combination with adjunctive NPWT. The primary outcome, time to re-epithelialisation, was assessed through a blinded photographic review. Resource usage and costs were prospectively recorded for each participant for up to 6 months. Incremental cost-effectiveness ratios and dominance probabilities were estimated and uncertainty quantified using bootstrap resampling. Mean costs per participant—including dressings, labour, medication, scar management, and theatre operations—were lower in the NPWT group (AUD $903.69) relative to the control group (AUD$1669.01). There was an 89% probability that NPWT was dominant, yielding both faster re-epithelialisation and lower overall costs. Findings remained robust to sensitivity analyses employing alternative theatre costs and time-to-re-epithelialisation estimates for grafted patients. In conclusion, adjunctive NPWT is likely to be a cost-effective and dominant treatment for small-area paediatric burns (ANZCTR.org.au:ACTRN12618000256279)

Study of negative pressure wound therapy as an adjunct treatment for acute burns in children (SONATA in C): protocol for a randomised controlled trial

Background: Although negative pressure wound therapy (NPWT) is widely used in the management of several wound types, its efficacy as a primary therapy for acute burns has not yet been adequately investigated, with research in the paediatric population particularly lacking. There is limited evidence, however, that NPWT might benefit children with burns, amongst whom scar formation, wound progression and pain continue to present major management challenges. The purpose of this trial is to determine whether NPWT in conjunction with standard therapy accelerates healing, reduces wound progression and decreases pain more effectively than standard treatment alone. Methods/design: A total of 104 children will be recruited for this trial. To be eligible, candidates must be under 17 years of age and present to the participating children's hospital within 7 days of their injury with a thermal burn covering <5% of their total body surface area. Facial and trivial burns will be excluded. Following a randomised controlled parallel design, participants will be allocated to either an active control or intervention group. The former will receive standard therapy consisting of Acticoat™ and Mepitel™. The intervention arm will be treated with silver-impregnated dressings in addition to NPWT via the RENASYS TOUCH™ vacuum pump. Participants' dressings will be changed every 3 to 5 days until their wounds are fully re-epithelialised. Time to re-epithelialisation will be studied as the primary outcome. Secondary outcomes will include pain, pruritus, wound progression, health-care-resource use (and costs), ease of management, treatment satisfaction and adverse events. Wound fluid collected during NPWT will also be analysed to generate a proteomic profile of the burn microenvironment. Discussion: The study will be the first randomised controlled trial to explore the clinical effects of NPWT on paediatric burns, with the aim of determining whether the therapy warrants implementation as an adjunct to standard burns management. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000256279. Registered on 16 February 2018.</p

Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small-area thermal burns in children

BACKGROUND: The efficacy of negative pressure wound therapy (NPWT) in the acute management of burns remains unclear. The purpose of this trial was to compare standard Acticoat™ and Mepitel™ dressings with combined Acticoat™, Mepitel™ and continuous NPWT to determine the effect of adjunctive NPWT on re-epithelialization in paediatric burns. METHODS: This two-arm, single-centre RCT recruited children with acute thermal burns covering less than 5 per cent of their total body surface area. The primary outcome was time to re-epithelialization. Blinded assessments were performed using photographs captured every 3-5 days until discharge. Secondary measures included pain, itch, grafting, perfusion and scar management referrals. RESULTS: Some 114 patients were randomized. Median time to re-epithelialization was 8 (i.q.r. 7-11) days in the NPWT group and 10 (8-14) days in the control group. In a multivariable model, NPWT decreased the expected time to wound closure by 22 (95 per cent c.i. 7 to 34) per cent (P = 0·005). The risk of referral to scar management was reduced by 60 (18 to 81) per cent (P = 0·013). Four participants in the control group and one in the NPWT group underwent grafting. There were no statistically significant differences between groups in pain, itch or laser Doppler measures of perfusion. Adverse events were rare and minor, although NPWT carried a moderate treatment burden, with ten patients discontinuing early. CONCLUSION: Adjunctive NPWT hastened re-epithelialization in small-area burn injuries in children, but had a greater treatment burden than standard dressings alone. Registration number: ACTRN12618000256279 ( http://ANZCTR.org.au)

Cool running water first aid decreases skin grafting requirements in pediatric burns: a cohort study of two thousand four hundred ninety-five children

Study objective: First-aid guidelines recommend the administration of cool running water in the early management of thermal injury. Our objective is to analyze the associations between first aid and skin-grafting requirements in children with burns. Methods: This cohort study used a prospectively collected registry of patients managed at a tertiary children’s hospital. Multivariate logistic regression models were used to evaluate the relationship between first aid and the requirement for skin grafting. Secondary outcomes included time to re-epithelialization, wound depth, hospital admission and length of stay, and operating room interventions. Adequate first aid was defined as 20 minutes of cool running water within 3 hours of injury. Results: In our cohort of 2,495 children, 2,259 (90.6%) received first aid involving running water, but only 1,780 (71.3%) were given the adequate duration. A total of 236 children (9.5%) required grafting. The odds of grafting were decreased in the adequate first aid group (odds ratio [OR] 0.6; 95% confidence interval [CI] 0.4 to 0.8). The provision of adequate running water was further associated with reductions in full-thickness depth (OR 0.4; 95% CI 0.2 to 0.6), hospital admission (OR 0.7; 95% CI 0.3 to 0.9), and operating room interventions (OR 0.7; 95% CI 0.5 to 0.9), but not hospital length of stay (hazard ratio=0.9; 95% CI 0.7 to 1.2; P=.48). Conclusion: Burn severity and clinical outcomes improved with the administration of cool running water. Adequate first aid must be prioritized by out-of-hospital and emergency medical services in the preliminary management of pediatric burns