Bubble Wrap Live 2019 – Article List

Cite this article as:
Team DFTB. Bubble Wrap Live 2019 – Article List, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20064

At DFTB19, we had three great talks during the Bubble Wrap Live session. Whilst the videos and podcasts from these talks are still in the works, here’s the list of articles referenced for you to check out ahead of time.

5 Paediatric Emergency Papers

Edward Snelson @sailordoctor

PREDICT: Head Injury and Delayed Presentations to ED

Borland ML, et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Annals of Emergency Medicine, 2018;75 (1):1-10

Oral Prednisolone for preschool viral induced wheeze

Foster SJ, et al. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018;6(2):97-106

Clinical Prediction Rule for Febrile Infants under 60 days

Kupperman N, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr.2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501

Whole body CT for children with Trauma

Abe T, et al. Is Whole-Body CT Associated With Reduced In-Hospital Mortality in Children With Trauma? A Nationwide Study. Pediatr Crit Care Med. 2019 Jun;20(6):e245-e250. doi: 10.1097/PCC.0000000000001898.

ECLIPSE study

Lyttle MD, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE). The Lancet . 2019;393(10186):2125-2134

 

5 General Paediatrics Papers

Susie Piper @chookiemama

Probiotics and Gastroenteritis

Freedman SB, et al. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med 2018; 379:2015-2026 DOI: 10.1056/NEJMoa1802597

Acetaminophen and Febrile Seizure Recurrence

Murata S, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics 2018; 142(5): pii: e20181009. doi: 10.1542/peds.2018-1009. Epub 2018 Oct 8.

Hi flow vs CPAP in SCN (HUNTER trial)

Manley BJ, et al. Nasal High‐Flow for Early Respiratory Support of Newborn Infants in Australian Non‐Tertiary Special Care Nurseries (The Hunter Trial): A Multicentre, Randomised, Non‐Inferiority Trial. J Paediatr Child Health. 2018;54:4-4. doi:10.1111/jpc.13882_4

Rudeness and Medical Performance

Riskin A, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015;136:487-495.

Katz D, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis.

LEGO and poo!

Tagg A, et al. Everything is awesome: Don’t forget the Lego.  2018 Nov 22. doi: 10.1111/jpc.14309. [Epub ahead of print]

 

Paediatric Surgery Papers

Craig McBride @paedsurg

Tissue Paper: Paediatric Burn Wound Care

Brown E.A, et al. Impact of Parental Acute Psychological Distress on Young Child Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care. J Clin Psychol Med Settings (2019). https://doi.org/10.1007/s10880-018-9596-1

Brown NJ, et al. Play and heal: Randomized controlled trial of Ditto™ intervention efficacy on improving re-epithelialization in pediatric burns. Burns. 2014;40:204–13.

Paper Planes: Telehealth in Paediatrc Surgery

Brownlee GL, et al. Telehealth in paediatric surgery: Accuracy of clinical decisions made by videoconference. J Paediatr Child Health. 2017;53(12)

Rees CM, et al. Probiotics for the prevention of surgical necrotising enterocolitis: systematic review and meta-analysis.

Sandpaper: Bullying & Discrimination in Surgery

Crebbin, W. , Campbell, G. , Hillis, D. A. and Watters, D. A. (2015), BDSH in surgery in Australasia. ANZ J Surg, 85: 905-909. doi:10.1111/ans.13363

Watters, D. A. (2015), Apology for discrimination, bullying and sexual harassment by the President of the Royal Australasian College of Surgeons. ANZ J Surg, 85: 895-895. doi:10.1111/ans.13362

 

 

DFTB20 will be held in Brisbane, Australia. If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Cutting edge burns management: Fiona Wood at DFTB18

Cite this article as:
Team DFTB. Cutting edge burns management: Fiona Wood at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18295

Professor Fiona Wood, AM, is one of the worlds leading burns surgeons.  Having qualified from St Thomas’ in London she decided to do what so many of us do and move down under. Since the early days of her career, she has recognized that to improve the outcomes of burns victims involves not just scarless skin but also healing in mind and spirit. Along with Marie Stoner, she pioneered the use of ‘spray-on skin’ and is well known for the care she provided to the victims of the Bali bombings back in October 2002.

In this talk, she talks about the past, the present and the future of burns care whilst championing the roles of women in medicine and surgery. As a mother of six children, she reminds us all that there is nothing that cannot be achieved if you ask for it.

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 

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Treadmill Burns

Cite this article as:
Henry Goldstein. Treadmill Burns, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9710

Chase, 3, is brought in by ambulance with his hand wrapped in a towel. His sweaty father – wearing running gear – explains that Chase touched the treadmill whilst Dad was in full flight.

A recently published paper in Burns reviews the epidemiology of treadmill burns;

Goltsman D, Li Z, Connolly S, Meyerowitz-Katz D4, Allan J, Maitz PK Pediatric Treadmill Burns: Assessing the effectiveness of prevention strategies.Burns. 2016 Aug 10. pii: S0305-4179(16)00064-4. doi: 10.1016/j.burns.2016.02.007. [Epub ahead of print]

Goltsman and colleagues reviewed a set of 298 treadmill burns sustained over a 10 year period in NSW, Australia.

Treadmills seem oddly specific, why the focus? Treadmill burns deserve our attention for three reasons;

Prevalence:

Firstly, they are relatively common in the paediatric population, accounting for around 1 in 20 burns.

They’re most common in the 0-5 age group (mean age – 3.8yrs)

More often males; 62%

Treadmill burns are classically small, at less than 1% TBSA.

85% were burns to the hand, with a total of 91% being somewhere on the upper limb.

The lower limb, torso and head & neck each accounted for 4%, 5% and 7% of treadmill burns, respectively.

Pathophysiology:

Secondly, the pathophysiology of treadmill burns is complex.

The basic mechanism is friction. Often, there is also entrapment of limbs, fingers or toes causing extensive and penetrating burns. Blunt trauma may occur when a child falls off the machine.

It is postulated that friction burns in children are particularly severe as their withdrawal reflex is relatively developmentally immature, and their volar epidermis is thinner. In concert, the slow reflex leads to prolonged burn time through more vulnerable skin.

In this data set, 62% of burns were full thickness.

Management:

 Three quarters of the treadmill burns reviewed received no or inadequate first aid. First aid should be provided as per a typical thermal injury with 20 minutes of cool running water.

A significant number require reconstructive surgery; half the patients who sustained a treadmill burn received skin grafts.

An entrapment injury sustained whilst the treadmill was operating was more likely to require grafting.

How might we reduce the prevalence of treadmill burns?

The study data was obtained at a time when legislative changes led to mandatory safety warnings on treadmills. In addition to a multimodal public health campaign, there was a decrease in the annual number of treadmill burns throughout the study period. Yet, the most recent data (from 2014) still sees treadmill burns account for 4% of all paediatric burns.

Goltsman et al., moot the following suggestions to further reduce the risk of treadmill burns in children;

1. Safety devices could make it impossible for a child to start a treadmill;

2. Treadmills could have sensors in the area of danger for friction burns to automatically stop in case a body part gets trapped there;

3. The ‘‘stop’’ mechanism should be easy to reach even after a person has fallen from the treadmill, not just from a standing position; or

4. In order to prevent parents who are using the treadmill from failing to notice children standing or crawling right next to them behind the treadmill, the running treadmill could stop, or play an ‘‘alarm’’ noise if anyone comes close.

This study compliments and earlier review undertaken by Jermijenko et al in 2008;

Jeremijenko L, Mott J, Wallis B, Kimble R. Paediatric treadmill friction injuries. J Paediatr Child Health. 2009 May;45(5):310-2. doi: 10.1111/j.1440-1754.2008.01329.x. Epub 2008 Jun 12.

Polly put the kettle on… and poured a cup of tea

Cite this article as:
Amie Beattie. Polly put the kettle on… and poured a cup of tea, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9038

Jack, a 2 year old boy, is rushed into the Emergency Department by his distraught mother, Polly. She had just poured a cup of tea and prior to adding milk, Jack reached up to the kitchen table, pulling the tea toward himself and sustaining a burn to his neck and chest. You recall an article that was presented at Journal Club recently – ‘Airway compromise in children with anterior neck burns: Beware the scalded child’, and you wonder what to do next….

Minor burns

Cite this article as:
Andrew Tagg. Minor burns, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3266

Jasmina, a five old girl, is brought in by her mother after a Sunday afternoon barbecue.  Having had very little for breakfast she became very excited when the burgers came out and reached out to grab one from the grill burning her hand.

 Bottom line

  • Simple first aid is often forgotten and cold running water for at least 20 minutes may be effective up to 3 hours after the burn.
  • Grading the severity of a burn can be tough.  It is easy for experts to get it right in retrospect.
  • Follow local guidelines with regard to wound management (de-roofing blisters) and dressing choice.
  • Don’t forget tetanus prophylaxis in non-immunized children.
  • Although not mentioned in this article always ask yourself if the burn could be a sign of non-accidental injury.

What immediate first aid should be done at home BEFORE coming to the ED?

Whilst grandmothers may advocate using butter, turmeric or Tiger balm the most important thing to do is…To hold the hand under cool running water for at least 20 minutes. If this has not been done prior to presentation and the patient is seen within 3 hours then this should be done in the emergency department. If they don’t have access to cold running water then immersion in cool water may be of some benefit.

Victoria Ambulance and a number of first aid kits use Burnaid®, a hydrocolloid dressing impregnated with melaleuca oil as their primary dressing. It helps keep the burn moist, is easy to take down so everyone can take a look at the burn and, most importantly, it smells nice.

What burns should be referred to a regional burns centre?

Other than large area burns and inhalation injuries the following should be discussed with your local experts…”

  • Burns to special areas e.g. face, hands, feet or perineum
  • Full thickness burns > 5% TBSA
  • Electrical burns
  • Chemical burns
  • Circumferential burns of the limbs or chest
  • Burns as a result of suspected non-accidental injury

How do we grade burns?

As nobody understands first, second and third degree burns what approach can we use?Grading depth of burn is notoriously difficult. We should all be able to pick the superficial epidermal burn or the charred full thickness burn but there is some room for error in the middle ground. Often the grade of a burn will vary depending on who is doing it and when. Often the tincture of time helps differentiate a mid dermal burn from a deeper dermal burn.

Remember, too, that the majority of burns are heterogenous and contain a number of different components. This handy, dandy table, adapted from the Victoria Burns specialists should help. Remember to measure, check capillary refill and check sensation.

How are you going to clean the burns?

Once the patient is adequately analgesed you might consider removing any adherent clothing or pre-hospital creams and unguents so you can properly assess the burn. Intranasal fentanyl or diamorphine may make this process much less distressing. One of the main aims of cleaning the burn is to prevent bacterial infection hat would delay healing.

Most burns services recommend shaving the hair of the surrounding skin because of colonisation of the hair follicles. Limb, trunk or torso burns should be cleaned with 0.1% aqueous chlorhexidine or normal saline.

There is a great deal of controversy as to whether blisters should be left intact or de-roofed. Those in favour of de-roofing suggest it is impossible to gauge the depth of the burn without visualising it. Those against suggest that the blister fluid, being sterile, acts as a cushion against shear trauma for the healing skin as well as keeping the environment moist. As always be guided by local policies.

In Victoria the regional burns service recommends removal of the blisters using a sterile technique.

How are you going to dress the burns?

Once again local policy often trumps evidence but some type of dressing depends often on depth of burn. The ideal dressing should be non-adherent, highly absorbent and have some antimicrobial properties. Non-Adherent dressings make it easier to re-examine the burn without causing undue distress to the child.  Burns with a degree of blistering also need to be able to soak up the exudate unless the patient wants to wear it on their clothes.

Superficial/epidermal – these often require nothing more than aloe vera and a stern word

Superficial dermal (partial) – these often need something to soak up the exudate such as a foam or paraffin gauze, or a more flexible silicone based dressing e.g. Mepilex

Mid dermal to deep dermal – these wounds are often heavily contaminated and the majority of burns units now favour silver based dressing such as Acticoat©. In the past silver sulphadiazine (SSD) cream was used but this tended to stick to the wound necessitating more frequent dressing changes thus impairing healing.

The silver impregnated dressing acts as an antibacterial but dries out readily and requires water (not saline) to activate it. Once the silver dressing has been applied then a second layer of moist gauze should be applied over the top followed by crepe. After 24 hours or so the dressing should auto-activate as the burn exudate keeps the dressing moist. There is no evidence that prophylactic antibiotics reduce the incidence of infection.   Evidence for the use of silver impregnated dressings in superficial dermal burns is lacking and given their high relative cost there is a move to using them only for the deeper burns.

What should the family be told about aftercare of the burn?

Parents need to know what to expect to lessen the chance of an unplanned revisit. All but the most superficial of burns should be followed up, either in a specialist burns or plastics clinic or at planned intervals in the emergency room. In this era of smartphones parents can take a picture of the healing burn at each visit in case they are seen by a different healthcare professional.

A burn often looks very dramatic when it first occurs and that does make it hard to judge depth. It is easy to make mistakes and if it looks like the wound is not healing within the expected time frame then the patient should be promptly referred to the burns service for consideration of grafting. Burn skin may be a different colour to surrounding skin, may be hyperalgesic for a period of time and is much more likely to burn if exposed to the sun. Blisters may form but they should be dealt with by healthcare professionals at the next visit rather than risk infection.

Outcome

Jasmina had some erythema to her palm and immediate blistering to her fingertips, that was incredibly painful.  It was decided that the burn was a mixture of epidermal and superficial dermal. As the burns affected the finger tips of a young child the case was discussed with the local burns service who advised individual paraffin gauze dressings.  They arranged to see Jasmina in their next clinic.

Acknowledgements Thanks to Cameron Keating SET2 Registrar Plastics & Reconstructive Surgery & Prof Roy Kimble

References

The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia – https://www.vicburns.org.au/ – (accessed 29/07/2013)

Guthrie,K, Minor Burns in the Emergency Department – www.lifeinthefastlane.com (accessed 29/07/2013)

Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of an “ideal” burn wound dressing–what do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns. 2012 Nov;38(7):960-6

Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012 May;38(3):307-18

Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013 Mar 28

Wu C, Tan AL, Maze DA, Holland AJ. Instant hot noodles: do they need to burn? Burns. 2013 Mar;39(2):363-8