LETTERS TO THE EDITOR

Incorrect Acticoat applicationcausing iatrogenic injury to a childwith a palmar burnActicoat (Smith and Nephew, Melbourne, Vic., Austra-lia) is a nanocrystaline silver dressing which hasbroad spectrum antimicrobial and anti-inflammatoryactions.1,2 This dressing must first be moistened withsterile water to become effective.3 Acticoat has beenshown to significantly reduce the need for skin graftingin children with partial thickness burns and we recom-mend its use in the ED setting.4,5

Iatrogenic injury caused by the incorrect applicationof Acticoat to palmar burns is seen frequently in ourBurns Clinic. This letter highlights a recent case and weprovide recommendations for the prevention of thisinjury.

A 9-month-old boy presented to the Royal Children’sHospital Outpatient Burns Clinic, Melbourne, Australia,3 days after sustaining a partial thickness contact burnto his left palm. The initial injury was confined to thehypothenar eminence. He was first seen in an ED whereActicoat was applied (Fig. 1). Saturated circumferentialapplications of Acticoat and an overlying plastic wrapresulted in maceration of the entire hand and interdigi-tal shearing (Fig. 2).

To protect non-injured skin when dressing handburns with Acticoat, we recommend that:1. Acticoat should be moistened with sterile water, but

not dripping wet.2. Acticoat and overlying occlusive dressings should

not extend further than 1 cm beyond burn margins(Fig. 3).

3. Digits must first be separated before the hand isbandaged (Fig. 4).EDs play a vital role in treating the vast majority

of partial thickness burn injuries. Knowledge of the

Figure 1. Circumferential and overly wet dressings with noseparation of fingers.

Initial burn

Figure 2. Maceration of the entire hand and shearing of inter-digital skin.

Figure 3. Minimizing Acticoat and the plastic wrap to the areaof injury.

doi: 10.1111/j.1742-6723.2008.01073–1075,1081,1082.xEmergency Medicine Australasia (2008) 20, 183–188

© 2008 The AuthorsJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

potential complications associated with modern burnsdressings like Acticoat is important in this progressingfield.

Conflicting interest

No conflict of interest is identified.

Shinichiro Sakata, Simone West, Craig McBride

and Russell Taylor

Paediatric Burns Unit, Royal Children’s Hospital,

Melbourne, Victoria, Australia

References

1. Yin QH, Langford R., Burrell E. Comparative evaluation of theanti-microbial activity of Acticoat™ antimicrobial barrier dress-ing. J. Burn. Care Rehabil. 1999; 20: 195–200.

2. Olson ME, Wright JB, Lam K, Burrell RE. Healing of porcinedonor sites covered with silver-coated dressings. Eur. J. Surg.2000; 166: 486–9.

3. Instructions for Using Acticoat®. [cited 1 March 2008.] Availablefrom URL: http://www.acticoat.com

4. Royal Children’s Hospital Clinical Practice Guidelines 2007. [cited1 March 2008.] Available from URL: http://www.rch.org.au/burns

5. Cuttle L, Naidu S, Mill J, Hoskins W, Das K, Kimble RM. Aretrospective cohort study of Acticoat versus Silvazine in a pae-diatric population. Burns 2007; 33: 701–7.

Difficult airway equipment inAustralian adult emergencydepartments

The incidence of difficult endotracheal intubation ishigher in the ED (3–5.3%) than in the controlled settingof the operating theatre (1.15–3.8%).1 The AmericanSociety of Anaesthesiology and the Difficult AirwaySociety have devised a difficult airway managementalgorithm and a recommended list of difficult airwayequipment. In spite of these recommendations, there is awide variation in the equipment available in the ED.2–6

In order to identify the availability of difficult airwayequipment in Australian adult EDs, we conducted asurvey of the 80 adult EDs accredited by ACEM for aminimum of 6 months’ advanced training. The resultsare summarized in Table 1, It is encouraging that alldepartments surveyed possessed at least one alternativedevice for both ventilation and intubation as well as thebasic adjuncts for airway management. In contrast,21% of emergency medicine programmes in the USAdid not possess an alternative device for either ventila-tion or intubation, and 11% of English departments didnot hold an alternative ventilation device.5,6 The major-ity (76%) stored these devices in a separate portableairway trolley or box. Tertiary referral hospitals weremore likely than non-tertiary hospitals to possess aMcCoy laryngoscope (70% vs 42%), a fibreoptic bron-choscope in the ED (15% vs 3.5%) and a portable diffi-cult airway container (84% vs 67%), respectively. TheMcCoy laryngoscope is available in 48% of departmentsand has a pivotable tip at the end of the blade allowingthe user to pull the epiglottis anteriorly for a better view.In patients with in-line cervical immobilization whoinitially have a Grade III view, the McCoy blade hasbeen shown to improve the view by one grade in 83% ofcases.7 It is interesting to note that 17 (22%) depart-ments possess a fibreoptic device of some kind, reflect-ing the increasing comfort of Australian emergencyphysicians with these devices., The majority of intuba-tions carried out in the ED are straightforward, but werecommend that every emergency airway be treated asa potentially difficult airway. The present study dem-onstrates that Australian EDs compare favourably withother countries in relation to the availability of difficultairway equipment. It is vital that staff be familiar withthese devices and that an agreed difficult airway algo-rithm is in place. We believe that further improvementscan be made by the increased use of clearly labelledportable storage containers in one of the resuscitation

Figure 4. Separating the digits to protect them from macera-tion and pressure.

Letters to the Editor

184 © 2008 The AuthorsJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

areas and that this container should be at hand for allintubations.

Martin Rochford, Brent Skippen and Martin Duffy

Department of Emergency Medicine, St. Vincent’s Hospital,

Sydney, New South Wales, Australia

References

1. Crosby ET, Cooper RM, Douglas MJ et al. The unanticipateddifficult airway with recommendations for management. Can. J.Anaesth. 1998; 45: 757–76.

2. Henderson JJ, Popat MT, Latto MT, Pearve AC. Difficult airwaysociety guidelines for the management of the unanticipated dif-ficult intubation. Anaesthesia 2004; 59: 675–94.

3. American Society of Anesthesiologist Task Force. Practiceguidelines for the management of the difficult airway. Anupdated report by the American Society of AnesthesiologistTask Force on management of the difficult airway. Anesthesiol-ogy 2003; 98: 1269–77.

4. Graham CA, Brittliff J, Beard D, McKeown DW. Airway equip-ment in Scottish emergency departments. Eur. J. Emerg. Med.2003; 10: 16–18.

5. Morton T, Brady S, Clancy M. Difficult airway equipment inEnglish emergency departments. Anaesthesia 2000; 55: 475–88.

6. Levitan RM, Kush S, Hollander JE. Devices for difficult airwaymanagement in academic emergency departments: results of anational survey. Ann. Emerg. Med. 1999; 33: 694–8.

7. Uchida T, Hikawa Y, Saito Y, Yasuda K. The McCoy leveringlaryngoscope in patients with limited neck extension. Can. J.Anaesth. 1997; 44: 674–6.

Improving major trauma careoutside tertiary centres:development and implementationof a statewide paediatric traumaeducation programmeAlthough trauma is the leading cause of death in chil-dren and adolescents aged 1–16 years in many coun-tries, it is a relatively infrequent event outside tertiarytrauma centres. Its management requires high levels ofexpertise, teamwork and appropriate clinical resources.Trauma care in Australia outside metropolitan areashas to cope with relative isolation, restricted resourcesand long distances to gain access to emergency care ingeneral and to definitive tertiary specialist trauma carein particular.

In Victoria, Australia, a number of deficiencies intrauma management have been identified.1–4 Based on agovernmental review of trauma care,5 a statewidetrauma system was created in Victoria, including triageof major trauma patients to designated major traumaservices (MTS). It was also recognized that furtherimprovements in trauma care would have to addresscare provided in rural and remote locations prior totransfer to these designated trauma centres.

Currently used trauma education programmes, suchas the advanced trauma life support (ATLS) course andthe trauma elements of the advanced paediatric lifesupport (APLS) course, are limited in their scope onpaediatric trauma care and do not address some of theissues faced by rural and remote practitioners.

Table 1. Difficult airway equipment in Australian adult EDs

Item of equipment No. departmentspossessing item

n = 79 (% [95% CI])

Basic EquipmentCurved laryngoscope blade 79 (100 [95–100])Straight laryngoscope blade 74 (93 [86–97])McCoy laryngoscope 38 (48 [37–59])Gum elastic bougie 79 (100 [95–100])Stylet 79 (100 [95–100])

Alternative intubation equipmentSurgical airway device 79 (100 [95–100])Retrograde intubation kit 23 (29 [20–40])Intubating laryngeal mask airway 48 (61 [50–71])Aintree catheter 3 (4 [1–9])Lighted stylet 10 (13 [7–22])Rigid laryngoscope (e.g. Bullard

laryngoscope)4 (5 [2–12])

Glidescope 7 (9 [4–17])Bronchoscope in the ED 6 (8 [4–16])Bronchoscope in anaesthetic

department70 (89 [80–94])

Alternative ventilation equipmentLaryngeal mask airway 79 (100 [95–100])Proseal laryngeal mask airway

(ProSeal LMA)11 (14 [8–23])

Needle cricothyroidotomy kit 75 (95 [88–98])Combitube 13 (17 [10–26])

OtherPortable difficult airway

trolley/box60 (76 [66–84])

End-tidal carbon dioxidedetector (ETCO2)

79 (100 [95–100])

ETCO2 routinely used for allintubations

77 (98 [91–99])

Other devices not mentionedExchange catheter 10 (13 [7–22])Kessel laryngoscope blade 3 (4 [1–9])

Letters to the Editor

185© 2008 The AuthorsJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

In response to these educational needs, a compre-hensive paediatric major trauma education programmewas developed by a team of educators and senior cli-nicians at Royal Children’s Hospital (RCH), Melbourne,Victoria, the paediatric MTS for the state of Victoria,and implemented state wide. The education pro-gramme comprises of standardized paediatric traumaguidelines in the form of a manual and a CD-ROM andpaediatric trauma seminars. The manual covers allaspects of initial paediatric trauma resuscitation andmanagement and incorporates useful charts fromburns fluid management to trauma resuscitationrecords. The same information is available on aCD-ROM with downloadable trauma charts, digitalimages and videos of procedures. It also contains mul-tiple choice type questions to test the user’s knowl-edge. Manual and CD-ROM can be used as an ongoinglearning tool or to provide emergency informationfor a patient presenting after trauma. The paediatrictrauma education programme followed a structuresimilar to previously accepted and trialled educationalcourses, such as APLS and ATLS, and included corelectures, scenario stations and skill stations.

Course faculty provided by RCH consisted of experi-enced and motivated nursing and medical specialists.The programme was customized for local needs andsettings, for example, operating without blood transfu-sion or radiography capability, and allowed staff towork in their typical roles.

Implementation was organized by RCH traumaservice staff and coordinated with the five regionaltrauma coordinators. Trauma manuals and CD-ROMwere distributed free of charge to over 200 hospitalsthroughout Victoria. The CD-ROM has been registeredto approximately 150 computers across Victoria. Overthe 4 year implementation period, 568 staff involved inemergency trauma care have participated in 26 paedi-atric trauma seminars. Based on a 95% return rate, 99%of evaluations reported the course as being very worth-while for their practice and that the course increased theknowledge base. Feedback was used to improve coursecontent and structure.

Participants are charged for participation and theprogramme is cost-neutral. All courses are fully booked.Participation in the course has been recognized by theRoyal Australian College of General Practitioners forcontinuing medical education points.

Although feedback from participants and fromstaff at the MTS is overwhelmingly positive, it is dif-ficult to measure the impact of this programme on thedelivery of trauma care. However, the programme has

clearly had a major impact on the understanding andcommunication between non-tertiary centres and theMTS. Where rural and remote providers haveimproved knowledge and skills for trauma manage-ment, staff at the MTS have learned to appreciate thedifficulties and limitations these providers are facedwith in providing trauma care in a resource-poor,remote environment.

CD and manuals have also been delivered free ofcharge to many developing countries and are avail-able for purchase at cost to interested parties outsideVictoria.

Acknowledgement

We thank the senior medical and nursing staff for theircontribution to the development and implementation ofthis education programme and participating practitio-ners for their feedback. We thank the Victorian TraumaFoundation for grant support.

Catherine Bevan, Clara Officer and Franz E Babl

Trauma Service and Emergency Department, Royal Children’s

Hospital, Murdoch Children’s Research Institute, University of

Melbourne, Melbourne, Victoria, Australia

References

1. Cooper D, McDermott F, Cordner S, Tremayne A. Quality assess-ment of the management of road traffic fatalities at a level 1trauma center compared with other hospitals in Victoria, Aus-tralia. The Consultative Committee on Road Traffic Fatalities inVictoria. J. Trauma 1998; 45: 772–9.

2. Danne P, Brazenor G, Cade R et al. The major trauma manage-ment study: an analysis of the efficacy of current trauma care.Aust. N. Z. J. Surg. 1998; 68: 50–7.

3. McDermott F, Cordner S, Tremayne A. Evaluation of the medicalmanagement and preventability of death in 137 road trafficfatalities in Victoria, Australia: an overview. The ConsultativeCommittee on Road Traffic Fatalities in Victoria. J. Trauma 1996;40: 520–33;discussion 533–5.

4. McDermott F, Cordner S, Tremayne A. Management deficienciesand death preventability in 120 Victorian road fatalities (1993–1994). The Consultative Committee on Road Traffic Fatalities inVictoria. Aust. N. Z. J. Surg. 1997; 67: 611–18.

5. Ministerial Taskforce on Trauma and Emergency Services andthe Department of Human Services Working Party on Emer-gency and Trauma Services. Review of Trauma and EmergencyServices – Victoria 1999. Melbourne: Department of HumanServices, 1999.

Letters to the Editor

186 © 2008 The AuthorsJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Adding confusion to first aid forjellyfish stingsI write in response to the article published by Little inthe February issue of Emergency Medicine Australasiaregarding the first aid management of jellyfish stings.1

Also concerning the subsequent press release from theAustralasian College for Emergency Medicine (ACEM),as both are misleading, contain inaccurate informationand are critical of the Australian Resuscitation Council(ARC). The ARC revised and re-issued its guideline forjellyfish stings in July 2007.2 This was following a sys-tematic review of the published data and extensiveconsultation with member organizations of the ARC,which included ACEM. This process was consistentwith the National Health and Medical Research Coun-cil’s recommendation for developing clinical practiceguidelines. The revised guideline now recommends theuse of hot water for Physalia sp. (Bluebottle), which isconsistent with the evidence and has been available onthe ARC website (http://www.resus.org.au).2

Accordingly, we are somewhat surprised that neitherthe article’s author nor reviewers were aware of therelease of this updated ARC guideline, as there had beenextensive consultation nationally. The article by Littlepresents no new information, and is opinion-based on anarrative review of published and unpublished data.1

Furthermore, we suggest that the author might nowhave even added to this confusion by referring tostudies on Box jellyfish in the same paragraph as theLoten study, which was solely on Bluebottle stings.3

The press release issued by ACEM has generated con-siderable interest from the media as the spectre of con-troversy is raised. The ARC encourages ongoingresearch by the author and others in this area, but is ofthe opinion that the information published in journals orby professional organizations needs to be contempora-neous and accurate.

Ian Jacobs

Associate Professor, National Chairman, Australian

Resuscitation Council, Melbourne, Victoria, Australia

References

1. Little M. First aid for jellyfish stings: do we really know what weare doing? Emerg. Med. Australas. 2008; 20: 78–80.

2. Australian Resuscitation Council.Guideline 8.9.6 Envenomation– Jellyfish Stings. July 2007, pp. 1–5. [Cited Feb 2008.] Availablefrom URL: http://www.resus.org.au/

3. Loten C, Stokes B, Worsley D et al. A randomised controlled trialof hot water (45oC) immersion versus ice packs for pain relief inbluebottle stings. Med. J. Aust. 2006; 184: 329–33.

Author’s replyI thank Professor Jacobs, National Chairman of the Aus-tralian Resuscitation Council (ARC) for his comments.1 Imake the following observations. My article ‘First aidfor jellyfish stings: Do we really know what we are doing? ’was written in reference to the July 2007 ARC Guideline8.9.6 for Jellyfish Stings.2,3

Interestingly, Professor Jacobs, in supporting thislatest ARC guideline, has supplied no hard evidence tosupport the use of ice as first aid for jellyfish stings.Similarly, readers will remember that for many years,the ARC recommended pressure immobilization ban-daging for jellyfish stings in tropical Australia, withoutany evidence to support that. The ARC’s recommenda-tion was changed in 2005 after debate that followed apaper in this journal.4

It is disappointing that the ARC took 17 months fromthe electronic release of the Loten et al. paper before theARC jellyfish sting guideline was changed in July 2007to reflect this paper’s findings.5 Moreover, the ARC stillrecommend ice for Bluebottle (Physalia sp.) stings if heatis not available, when the benefit of ice appears to beone of placebo.3,5

In the paragraph where I have discussed Currie andJacups’s report showing the lack of effect of ice in boxjellyfish stings, followed by comments on Loten’s paper,I had clearly already indicated in my opening paragraphthat Loten’s paper referred to Bluebottle Physalia sp.jellyfish.5,6

The press release from the Australasian College forEmergency Medicine about my paper, referred to byProfessor Jacobs, accurately reflected the findings of thepaper. Thus, as most people, when stung by a jellyfish,will be unable to identify the species responsible, andwith Physalia sp. being found throughout tropical andnon-tropical Australia, the ARC guideline means thatthere will be two different options for first aid. This iswhere the confusion will be.

In conclusion, I maintain that the latest ARC jellyfishsting guideline is confusing, as there is little evidence tosupport the use of ice, and that heat has more solidevidence. Further research is required.

Letters to the Editor

187© 2008 The AuthorJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Mark Little

Department of Emergency Medicine, Caboolture Hospital,

Caboolture, Queensland, Australia

References

1. Jacobs I. Adding confusion to first aid for jellyfish stings. Emerg.Med. Australas. 2008: 20: 187.

2. Little M. First aid for jellyfish stings: do we really know what weare doing? Emerg. Med. Australas 2008; 20: 78–80.

3. Australian. Resuscitation Council. Guideline 8.9.6 Envenomation– Jellyfish Stings. July 2007, pp. 1–5. [Cited 4 Jan 2008.] Availablefrom URL: http://www.resus.org.au/

4. Little M. Is there a role for the use of pressure immobilizationbandages in the treatment of jellyfish envenomation in Austra-lia? Emerg. Med. (Fremantle) 2002; 14: 171–4. (Erratum. Emerg.Med. [Fremantle] 2002; 14 : 341).

5. Loten C, Stokes B, Worsley D et al. A randomised controlled trialof hot water (45oC) immersion versus ice packs for pain relief inbluebottle stings. Med. J. Aust. 2006; 184: 329–33.

6. Currie BJ, Jacups SP. Prospective study of Chironex fleckeri andother box jellyfish stings in the ‘Top End’ of Australia’s NorthernTerritory. Med. J. Aust. 2005; 183: 631–6.

Letters to the Editor

188 © 2008 The AuthorJournal compilation © 2008 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine