Today I’d like to welcome to the PodMD studio Dr Suzanne Rea

Dr Suzanne Rea is a Specialist Plastic Surgeon at Fiona Stanley Hospital and Perth Children’s Hospital and the newly opened Scar Clinic Perth, and a clinician scientist with a special interest in burn surgery and scar treatment.

Dr Rea completed her undergraduate medical degree at the Royal College of Surgeons of Ireland and obtained her fellowship in Plastic Surgery from the Royal College of Surgeons. After relocating to Western Australia, she completed a fellowship in Burns Surgery under the supervision of Professor Fiona Wood. Suzanne was awarded her fellowship from the Royal Australasian College of Surgeons in the specialty of plastic and reconstructive surgery in 2014. She was also awarded a doctorate by research (PhD) for her research on scarring which she completed at the University of Western Australia.

Today, we’ll be discussing the topic of paediatric and adult burns.

*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

The topic of today’s discussion is adult and paediatric burns. Suzanne, can you give us a brief overview about burns for these two groups?

Suzanne: Sure, burns are an injury that can happen in an instant and can result in life changing injuries. But most patients who get burnt thankfully, they’re just relatively minor burns, about 1% of the Australian population will experience a burn injury each year, but the vast majority of those are treated in GP’s in, you know, general family practice centres, in minor injury departments and really only about 3500 patients require admission to a major burns unit each year. And the key factor, I suppose, in determining the severity of that injury is the burning agent and the time in contact with that agent.

What are the key differences between burns for paediatric and adult patients?

Suzanne: So the commonest burning agents, regardless of age, are flame, scald and contact burns and really for children and adults, it just depends on the activities that they’re involved. So for example, the commonest injury in children is a paediatric toddler scald, so children under the age of five account for 80% of the burn injuries. That frequently happens at home, which is where they spend the majority of their time, sometimes in daycare, and it’s almost invariably a hot beverage scald. So tea, coffee. And in those under fives reaching up to the kitchen bench or to the kitchen or to the coffee table and putting that coffee down upon themselves. Resulting in a partial thickness paediatric scald.

As children get older, the next stage group is when kids actually start to do their own cooking and hot noodles are probably the most common cause of injury in that age group, and it’s often kids sit home alone 10/11/12 year-olds who take it out of the microwave, sit down on the sofa in front of their screen, have it sitting in their lap. Go to take a bite, realise it’s boiling hot and jump up and the entire pot falls in their lap. Very, very common and challenging to deal with both in terms of the age of the patient. You know you’re talking about early teens, adolescents and the physiological anatomical location of the burn. It’s a sort of sensitive area in a self-conscious teenager. So they’re all from the things that cause a problem.

As adults, as children become young adults, more commonly we see flame burns, often industrial and work-related accidents. So, the young working man, in particular, welding, angle grinding, burning off those types of things, and then through work-related campfires, are the gifts that keep on giving. We’d see campfire injuries all the time. Easter the Long Easter weekend is usually our busiest time of year for campfire injuries. The total fire bans have usually stopped and campfires become a problem. Mix campfires and alcohol and people do all sorts of funny things like, you know, jumping over the campfire. And seeing how long they can sit close to the campfire, etc.

The other things that we see quite seeing more frequently are two things. First of all, as patients are ageing and becoming more frail, we’re seeing more and more elderly scald patients. So almost back to that toddler period, those hot drinks that unsteadiness pulling their drinks down on top of themselves and more scald injuries in that age group and then in the diabetics is the other group that we see a big increase. They’ve got poor sensation, and peripheral neuropathies and they end up with foot burns in particular and they can be fairly complicated to manage. The big thing to be aware of both in the elderly and in children, is being aware of both non-accidental injury and in both age groups, so non-accidental injury in children. And unfortunately, elder abuse in the elderly is something that we’ve seen a little bit more.

How do you manage burns for paediatric patients?

Suzanne: So, the management of both paediatric and adult patients is similar. Obviously, the first thing you have to do is remove the burning agent if it’s safe to do so and so looking after your own safety, first stop, drop and roll removing it. If it’s a flame burn remove the source of the burning agent if it’s hot water etc. First aid is vitally important, it’s the biggest impact and biggest game changer in these patients. It can significantly impact the scar that that patient wears for life. Good first aid can change the need for surgery. 20 minutes of cool running water is effective right up until three hours from the time of injury, and that’s an important point we’ve seen in our research that frequently patients with burns will approach a caregiver within a healthcare provider within that three-hour period and actually first aid could have been done and then weren’t aware that that needed to be done.

The standard ABCs are obviously very important. Airway, breathing, circulation. If it’s a major burn and like standard EMST type management, but more commonly it’s a minor burn and that minor burn requires dressings. The protocol here in WA is a silver dressing for 48 hours then reassessment after that, which is when the burn usually has declared itself into the depths, and whether or not it requires further treatment. Obviously, burns greater than 15% will require fluid management and transfer to a burns unit, so there are two big groups that need to be divided. So the minor and the major.

Have there been any developments in the treatment of burns for these patients in the last few years?

Suzanne: So burn management of patients is constantly evolving. I suppose the biggest change really comes through with the dressing products and the availability of good silver antimicrobial dressings coupled with the use of good first aid has actually decreased the need for antibiotic usage, less infection and burns. Early surgery is now universally accepted as giving a better outcome, and then things like biological dressings, ReCell, which is colloquially known as spray on skin, and BTM, which is the temporising matrix devised in South Australia, which really has become a game changer in the treatment of major burns. It’s basically a type of artificial skin that integrates into the patient and provides an opportunity for that patient with a major burn to remain infection-free while we’re continuing to reconstruct the damaged skin. As that patient journey continues, things like scar management, including the development of lasers, have certainly improved the long-term outcomes of patients.

What are the potential long-term complications of burns in these groups?

Suzanne: So long-term complications can really be broken down into the physical and the psychological, and the physical implications depend on where the patient has been burned, the extent of the burn injury and the age at which they’ve been burnt. In particular in young children. Children have to grow and skin-grafted skin will not grow and that becomes a very real problem. So, for example, a contact burn on a hand, say from touching a pot belly stove – contact burns in children are very common from hot surfaces, and that little paediatric hand, say at the age of a 2-year-old has to grow to a full adult size. That’s about 8 centimetres. And to get that burn, which is maybe potentially tight across the palm to facilitate that growth, there is the requirement for multiple releases and actually multiple surgical procedures over time and that impacts then significantly on that patient’s hospital, you know, long term follow up in that you know there are multiple trips to the hospital multiple time off school time not being allowed participate in their activities that they want to do like swimming or sport.

And separate from that I suppose the psychological impacts on that child – the actual burn injury can have long-term psychological implications. This can often be a significant issue in children who experience bullying and we know that children can be quite cruel to each other and that can be a problem. And it’s also in parents because parents can also feel that they may have caused the accident so it can have lifelong implications for both parent and child

In adults, the implications can be around returning to work issues, especially if the accident happened at work and especially if an accident happened during the course of their normal activities. So, for example, someone who works in a kitchen or someone who works angle grinding or welding, we often see the most significant psychological impact is often on those patients as opposed to the catastrophic bush fire type injuries that can be almost explained as an act of nature. Whereas the ones that happen as part of everyday life seem to impact patients more significantly.

How can a GP assist in the management of burns for these patients?

Suzanne: So often the GP is the first point of contact for a burns patient. You know, a mum can come running in to the GP practice with a screaming toddler and it can be very confronting for everybody. Good pain relief, prompt attention to the ABC and good first aid are obviously the most important first step. And you know, I don’t need to tell GPs, but remaining calm in what is a very stressful situation is obviously super important. In more minor burns a good dressing, a silver dressing. The WA policy is the nanocrystalline silver dressing acticoat, elevation to minimise swelling and review at 48 hours really considering early referral to a burns unit – that referral doesn’t necessarily mean transfer, it might just mean a phone call to get some advice. Almost all the big burn units in Australia have excellent services to provide outreach, care or to provide advice via telehealth. So early referral is probably very important.

When should a GP refer?

Suzanne: 

So there are really two groups of acute injuries, so ANZBA the Australian, New Zealand Burns Association referral criteria are all full-thickness burns should be discussed with the local burns unit regardless of size, all chemical, all electrical, all burns of greater than 10%. Or burns of greater than 8% in small children. So the extremes of age, the very you know children and the elderly should be discussed. All inhalation injuries or circumferential injuries. And really, I suppose anyone who you have any concerns about. So if they’ve got a significant comorbid history. If they’ve got other issues that make them managing them in the community compromising it’s just better to have a chat and to see if there’s if they should be referred.

Suppose later some of the things that we’re seeing now are people who are being referred to us, who maybe had their initial surgery elsewhere, so. In a different country overseas or a long, long time ago, since the time of the accident. Quite a lot of things have changed in the management of burns over the last little while and we are seeing people who are presenting thinking have been referred by their GPs just to see if anything else can be done and you will be surprised what can be done. To people who have significant long-term scarring, it can be simple interventions like laser or more interventional surgeries, but it’s probably worth it if they haven’t seen someone for a long time re referring themselves, they can come in and have a chat and discuss those options.

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on paediatric and adult burns

Suzanne: I think the key to take home messages are:

First of all, first aid. As medics, we have been a bit dismissive of first aid and think that we should move to the next level. The evidence is very clear that good first aid and 20 minutes of cool running water can actually determine whether that patient needs an operation or not. And that will then impact the scar that that patient wears for the rest of their life. And so that is probably the biggest key factor.

Secondly, don’t underestimate the significance of even a minor burn on both the patient and the family in the short and the long term because those injuries can have significant consequences, and again, the evidence shows that injuries, whether they’re in visible or invisible parts of the body, can also have the same impact. So, we think the face and the hands are most important, but the patient can still be equally as troubled by an injury on the abdomen, for example.

Thirdly, consider early referral just by a phone call or seek advice from your local burns unit, I think you’ll find that most of them are very happy to discuss these patients. They don’t necessarily need a transfer, but the advice and the support are there to be availed of.

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