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Hand burns are common and treatment individualized, however given large volumes in some centers, pattern recognition may help optimize service provision. We performed a single center retrospective review from 2014 to 2018 of hand burns in patients aged 16 and over. Burns confined to the hands were considered isolated. We found 1163 patients (790 male, 68%), with 853 isolated (9% bilateral) and 310 non-isolated (35% bilateral) hand burns, and 12% were sustained in industrial workplaces. Most isolated burns received first aid (72%) and were scalds (41%) or contact (23%). Many presented to hospital by car (73%) and most were treated as outpatients (92%). Non-isolated burns were mainly flash (38%) or flame burns (25%, p < 0.01), with 66% given first aid, 49% used ambulances (p < 0.01) and 54% underwent hospital admission (p < 0.01). Non-isolated injuries had more full thickness involvement (p < 0.01), 13% were resuscitation burns and 10% received intensive care. Isolated and non-isolated burns are distinct clinical entities, as are unilateral and bilateral injuries. Isolated burns are usually unilateral scalds or contact burns, suited to outpatient treatment. Non-isolated burns are often flash or flame, bilateral, often needing ambulances, admission, and interventions. First aid can be improved, and consideration given to inpatient rehabilitation of bilateral hand burns., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Ltd and ISBI. All rights reserved.)

Background: Much of the recent literature on bromelain based enzymatic debridement of burn injury has focused on its use in smaller burn injury and specialist areas such as the hands or genitals (Krieger et al., 2012; Schulz et al., 2017a,b,c,d). This is despite the original papers describing its use in larger burn injury (Rosenberg et al., 2004, 2014). The current EMA license for Nexobrid™ advises that it should not be used for burn injuries of more than 15% TBSA and should be used with caution in patients with pulmonary burn trauma and suspected pulmonary burn trauma. The original safety and efficacy trial of NexoBrid™ limited its use to 15% TBSA aliquots with concern regarding the effect of bromelain on coagulation. In a European consensus paper of experienced burns clinicians, now on its second iteration, 100% of respondents agreed that "up to 30% BSA can be treated by enzymatic debridement based on individual decision" (Hirche et al., 2017). Hofmaenner et al.'s recent study on the safety of enzymatic debridement in extensive burns larger than 15% provides some further evidence that "bromelain based enzymatic debridement can be carried out safely in large-area burns" (Hofmaenner et al., 2020) but the literature is scant in these larger debridement areas. In our centre we have been using enzymatic debridement for resuscitation level burn injury since 2016. We have gained significant learning in this time; this article aims to describe our current protocol for enzymatic debridement in this patient population and highlight specific learning points that might aid other centres in using enzymatic debridement for larger burn injury., Method: We performed a search of the IBID database to identify all adult patients who satisfied the inclusion criteria of resuscitation level burn injury (defined as total burn surface area (TBSA) ≥15% in patients aged >16 years), or level 3 admission following burn injury and who underwent Enzymatic Debridement. A case note review was completed, and details comprising patient demographics, TBSA, mechanism of burn, presence of inhalation injury, sequencing of debridement, length of ICU and hospital stay, blood product utilisation and the need for autografting were recorded. No ethical approval has been sought for this retrospective review., Results: We identified 29 patients satisfying the inclusion criteria (Table 1). Between June 2016 and June 2020 the average total burn size of patients who had at least some of their burn treated by enzymatic debridement increased from 21.4% in 2016/17 to 34.7% in 2019/20. In these patients the actual area treated by enzymatic debridement also increased from 11.9% TBSA to 20.3% TBSA. 19 patients (66%) had enzymatic debridement performed within 24 h of injury, a further 2 patients (7%) within 48 h after injury. Patients were more likely to have enzymatic debridement commenced in the first 24 h after injury if they had circumferential limb injury (39% vs 9%) or were planned for enzyme only debridement (78% vs 28%). Those who were planned for combination enzyme and surgical debridement were more likely to have enzymatic debridement commenced after the first 48 h (75%). We have performed enzymatic debridement overnight on one occasion, for a patient who presented with circumferential limb injury and was determined to undergo urgent debridement., Conclusion: Much of the literature has described the use of enzymatic debridement in smaller burns, and specialist areas. However, it is our opinion that the advantages of enzymatic debridement appear to be greater in larger burns with a facility for whole burn excision on the day of admission in the ICU cubicle. We have demonstrated significantly reduced blood loss, improved dermal preservation, reduced need for autografting, and a reduction in the number of trips to theatre. We would advocate that both the team and the patient need to be as prepared as they would be for a traditional surgical excision. The early part of our learning curve for enzymatic debridement in resuscitation level injuries was steep, and we were able to build on experience from managing smaller injuries. We recommend any team wishing to using enzymatic debridement gain experience in the same way and develop robust local pathways prior to attempting use in larger burn injuries., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

The elderly constitute an expanding subgroup within society, and may have differences in health needs compared to younger patients. The specific needs and outcomes of elderly patients with burns have been widely studied. However, the definition of elderly often used in previous studies is a cut off of 65 years old. Within this broadly defined group, the very elderly may have distinct health care needs and issues. This study investigated aetiology, management and outcome of burns in those over 90 years treated at a single UK burns service over a period of 15 years between 1998 and 2013, and compares these data to published data describing 'younger' elderly burns patients. Twenty two patients were included, with a 2:1 female:male ration, and a mean 9%TBSA burn. Six of the 22 died during their admission, and those who survived averaged 8 days inpatient stay per %TBSA. The very elderly with burns may fare worse than younger elderly patients. Although burns in the very elderly are relatively infrequent events, they require significant resource. Further work to optimise their outcome is required., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Background: Many different burns mortality prediction models exist; however most agree that important factors that can be weighted include the age of the patient, the total percentage of body surface area burned and the presence or absence of smoke inhalation., Methods: A retrospective review of all burns primarily admitted to Pinderfields Burns ICU under joint care of burns surgeons and intensivists for the past 3 years was completed. Predicted mortality was calculated using the revised Baux score (2010), the Belgian Outcome in Burn Injury score (2009) and the Boston group score by Ryan et al. (1998). Additionally 28 of the 48 patients had APACHE II scores recorded on admission and the predicted and actual mortality of this group were compared., Results: The Belgian score had the highest sensitivity and negative predictive value (72%/85%); followed by the Boston score (66%/78%) and then the revised Baux score (53%/70%). APACHE II scores had higher sensitivity (81%) and NPV (92%) than any of the burns scores., Discussion: In our group of burns ICU patients the Belgian model was the most sensitive and specific predictor of mortality. In our subgroup of patients with APACHE II data, this score more accurately predicted survival and mortality., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

The National Burn Care Review prompted us to review trends in adult acute admissions to our unit with the intention to implement the guidelines of referral set down in the report. We had recently also adopted a more open admissions policy in keeping with these recommendations. This was achieved by a retrospective casenote analysis with the years 1981, 1991, and 2001 used as reference snapshot years to outline trends. The results showed an increase in the number of patients, a decrease in the depth and extent of burns, a decrease in the number of inpatient days and crude mortality rate. There was also a slight decrease in the age of patients.