A review series on the management of burns injury

In the southern hemisphere winter of 2019, the editors of Anaesthesia and Intensive Care (A&IC) discussed and agreed upon the idea of reintroducing theme issues containing a series of reviews and perhaps other articles on particular subjects that may be of interest to our readership. This is not a novel concept for A&IC or other journals. Indeed, the very first volume of A&IC featured a symposium issue on paediatric anaesthesia and intensive care (Vol. 1, No. 6, Nov. 1973) with Kester Brown appointed by Ben Barry as ‘Special Editor’.

We further decided that our theme-issue reintroduction would commence with an issue highlighting the surgical, anaesthetic, intensive care and pain management of burns injury. At the time, neither we nor the authors commissioned to undertake the reviews could have had any idea what burn-related challenges the summer of 2019–2020 would bring to the nations of Australia and New Zealand. Nor could we have known the extent to which some of our contributors were to become directly involved in the response to those challenges.

Many parts of Australia have been in the grip of a years-long drought. On 2 September, a fire started near Binna Burra in the Lamington National Park in South East Queensland. ¹ By a week later, there were another 130 fires burning in Queensland and New South Wales, and in late October, lightning ignited a fire at Gospers Mountain just north of Sydney. That fire would grow to become the largest individual bushfire ever recorded in Australian history, burning for more than two months and alone razing more than half a million hectares. Between July 2019 and March 2020, fires have burned through nearly 19 million hectares of land across almost every state and territory of Australia, killing at least a billion animals (some at risk of extinction), destroying more than 3500 homes and countless other buildings and infrastructure. Thirty-four lives have been lost as a direct result, and many people have been physically injured, not to mention the far-reaching psychological, economic and other consequences. Some of the fires on the east coast were extinguished only by a burst of very heavy rainfall that also broke records and, unfortunately, compounded the situation with significant flooding.

In the Bay of Plenty in New Zealand, meanwhile, the Whakaari/White Island volcano erupted suddenly and explosively in the early afternoon of 9 December 2019 while 47 tourists and guides were visiting. ² Thirteen died on the island, and of the 34 people rescued, all but a few suffered severe injuries and/or burns. Over the following weeks, a further eight of those succumbed. The rescue, local triage and initial care, retrieval to burns centres in New Zealand and subsequent repatriation of tourists to hospitals in Australia and elsewhere were all complex operations that severely stretched resources and expert manpower, particularly in New Zealand. Early management was challenging, as the volcano’s explosion resulted in some projectile injuries, but there were mainly respiratory and external burns and blast injuries from superheated steam and ash, with the further effects of hydrofluoric and sulphuric acids and infection with unusual microorganisms complicating these over subsequent days and weeks (Francois Stapelberg, pers. commun.). Several of the authors commissioned for the articles in this issue were directly involved in the emergency and later care of those injured in this disaster.

It is therefore timely that we present for our readers a series of articles on the management of burn injuries which, especially in their most severe forms, is challenging and difficult. Effective burns research also has many barriers, including the relatively low and unpredictable incidence of burn injury. The authors of these reviews were chosen based on their extensive experience in the clinical management of burns patients, as well as their expertise in burns research. The current theme issue begins with a historical cover note on burns resuscitation ³ and then includes two articles on recent developments in surgical burns management,^4,5 a detailed review of the techniques and challenges involved in anaesthesia and pain management of burn-injured patients, ⁶ another on the intensive care management of patients with inhalational injuries ⁷ and finally a paper on the particular challenges of effective communication during the care of younger patients with burns. ⁸ The information contained in these articles is up to date and has already been translated into the clinical setting, with dramatic improvement in outcomes for patients with extensive burns that was not imaginable a decade ago.

With this issue, we pay tribute to all those involved in our emergency and retrieval services, as well as the expert anaesthetists, intensivists, surgeons, nurses and other medical staff dedicated to the care of patients with burn injuries. And as we go to press facing the new and developing crisis of the COVID-19 pandemic, which will no doubt receive attention in subsequent issues, we at the Journal also take this opportunity to thank the countless people working around the world to control the situation, and to wish the very best to all our readers over the coming months, particularly those at the forefront of the response to this latest extraordinary challenge.