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Volume XXVI

Number 1

March 2013

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Summaries

3 BRAZILIAN KISS NIGHTCLUB DISASTER
(Atiyeh B., MD, FACS, President of Euro-Mediterranean Council for Burns and Fire Disasters)
5 NOSOCOMIAL INFECTIONS IN BURN PATIENTS: ETIOLOGY, ANTIMICROBIAL RESISTANCE, MEANS TO CONTROL
(Leseva M., Arguirova M., Nashev D., Zamfirova E., Hadzhyiski O. - Bulgaria)
The aim of our study was to determine the etiology of nosocomial infections, their changes over a period of five years (2007-2011), and the measures for control of infections and antimicrobial resistance in the Burns Clinic of the N.I. Pirogov University Multi-Profile Hospital for Active Treatment and Emergency Medicine, Sofia, Bulgaria. The medical records for all the patients and the database of the "Clinical Microbiology and Surveillance of Infections" National Information System were reviewed and analyzed to identify the microbial pathogens isolated in our burns Clinic. The three most frequent nosocomial pathogens were S. aureus, A. baumannii and P. aeruginosa. In order to control effectively nosocomial infections, a system of anti-infective and anti- microbial resistance measures has been developed and routinely implemented in our Clinic since 2008. Since 2009, thanks to this system, there has been a significant decrease in the rates of multi-resistant Staphylococcus aureus strains. Although at present the incidence of the nosocomial infections in our burns clinic is lower than in neighboring countries, several important infection control issues still need to be solved. We mainly rely on updating and strengthening the existing anti-infective system in order to control the spread of multi-drug resistant organisms, such as A. baumannii, extended spectrum beta-lactamase-producing Enterobacteriaceae, and carbapenem-resistant P. aeruginosa.
12 RENAL FAILURE IN BURN PATIENTS: A REVIEW
(Emara S.S., Alzaylai A.A. - Saudi Arabia)
Burn care providers are usually challenged by multiple complications during the management of acute burns. One of the most common complications worldwide is renal failure. This article reviews the various aspects of renal failure management in burn patients. Two different types of renal failures develop in these patients. The different aetiological factors, incidence, suspected prognosis, ways of diagnosing, as well as prevention methods, and the most accepted treatment modalities are all discussed. A good understanding and an effective assessment of the problem help to reduce both morbidity and mortality in burn management.
16 RENAL DYSFUNCTION IN BURNS: A REVIEW
(Ibrahim A.E., Sarhane K.A., Fagan S.P., Goverman J. - USA)
Acute kidney injury (AKI), although rare, is a major complication of burn injury that commonly leads to mortality. It results from a complex interplay of various cellular and neuro-humoral changes affecting burn patients. Guidelines for the treatment of this entity are still not well defined; therefore, prevention and early diagnosis are key to avoid the unfavorable prognosis of AKI. These entail a comprehensive understanding of the global physiologic changes underlying the condition of burn patients and a judicious interpretation of their continuous homeostatic alterations. The aim of this review is to present the salient features in burn patient physiology that contribute to AKI. Strategies for identifying early AKI are presented. Finally, the different treatment modalities are revisited.
26 THE REAL EXPANSION RATE OF MESHERS AND MICROGRAFTS: THINGS WE SHOULD KEEP IN MIND
(Kamolz L.P., Schintler M., Parvizi D., Selig H., Lumenta D.B. - Austria)
Skin graft expansion techniques (mesh and micrograft) are widely used, but there is ample evidence that skin graft meshers do not provide their claimed expansion rates. Although this finding might not be new for the majority of surgeons, less is known about surgeons' actual knowledge of expansion rates. The aim of this study was to evaluate the true expansion rates of commonly used expansion techniques with regard to claimed, achieved, and polled results. In the first part of the study, 54 surgeons were polled during an annual burns meeting regarding the most commonly used expansion techniques and expansion ratios; in the second step the true (achievable) expansion rates of the most widely used meshers and micrografts were analysed; and in third step, a poll involving 40 surgeons was conducted to estimate the true expansion rates of the most frequently used skin expansion techniques. The skin meshers (1:1.5 / 1:3) did not achieve their claimed values: (1:1.5) 84.7% of the claimed expansion (mean SD: 1:1.27 0.15) and (1:3) 53.1% of the 1:3 (1:1.59 0.15) mesher. The use of the micrografting technique resulted in 99.8% of the 1:3 (1:2.99 0.09), 93.6% of the 1:4 (1:3.74 0.12) and 93.8% of the 1:6 (1:5.63 0.12) claimed expansion rates, respectively. In general the surgeons overestimated the achievable expansion rates. In general the achieved expansion rate was lower than the estimated and claimed expansion rates. The micrografting technique provided reliable and valid expansion rates compared to the skin meshers. We recommend using the micrograft technique when large expansion ratios are required, for example in severe extensive burns.
30 PARENTAL AUTHORITY TO REFUSE ACUTE BURN TREATMENT VERSUS THE PROTECTION OUR CHILDREN DESERVE
(Al-Tarrah K., Khashaba H., Wilson Y., Al-Fadhli A., Moiemen N. - Kuwait)
Our society has empowered parents to care for their children and take legally binding decisions on their behalf. One of the areas where such decision making is required is in medical care when a child's health is at stake. Three cases of child abuse and neglect were identified and reported. Literature searches were done to identify cases of child abuse in Kuwait using Medline and PubMed. News of child abuse was searched for using search engines (bbc.co.uk, cnn.com, and foxnews.com). The British Child Protection Act and the Kuwaiti Criminal Prosecution Code were studied. Child abuse and neglect exist in Kuwait and are probably underreported. The laws in Kuwait are designed to punish child abuse once it has occurred rather than aiming at preventing it. It is reported that 75% of those responsible for child abuse are the parents. They retain full authority to restrict medical access. Medical staff are offered very limited support and are restricted as to what they can achieve due to the Kuwaiti legal infrastructure, which should be amended so as to protect children rather than prosecute offenders. A local authority has to be established and empowered to investigate, report, and act when suspicions of child abuse arise.
36 OUTCOMES OF PATIENTS WHO COMMIT SUICIDE BY BURNING
(Castana O., Kourakos P., Moutafidis M., Stampolidis N., Triantafyllou V., Pallantzas Ath., Filippa E., Alexandropoulos C. - Greece)
Cases in which people use fire when attempting or committing suicide are not common but nevertheless constitute a cause of admission to burns units worldwide. Usually these people are suffering from stress and have been diagnosed as mentally ill. Schizophrenia, depression, and personality disorders are the most frequently diagnosed conditions. The psychological problems appear to have been overlooked by the family or not to have been presented to them. The aim of this study is to present the clinical features, characteristics, and outcomes of patients burned during a suicide attempt. The role of the psychiatrist is important, starting in the emergency room. The incidence of patients committing self-injury by burning appears to be higher in women burn patients. Deceased patients usually have a larger extent of burns and a higher incidence of other injuries and require more surgical procedures and longer hospitalization times. The problems for burn unit staff and qualified psychiatric care are discussed.
40 AN UNUSUAL CASE OF EXTENSIVE SELF-INFLICTED CEMENT BURN
(Catalano F., Mariano F., Maina G., Bianco C., Nuzzo J., Stella M. - Italy)
Cement is a fine powder used to bind sand and stones into a matrix of concrete, making up the world's most frequently used building material in the construction industry. First described by Ramazzini in his book "De Morbis Artificia Diatriba" in 1700, the effect of cement on the skin was presumed to be due to contact dermatitis. The first cement burns case was published by Rowe and Williams in 1963. Cement handling has been found to be responsible for many cases of occupational burns (generally full-thickness) usually affecting a limited TBSA, rarely greater than 5%, with localization especially in the lower limbs. We describe an unusual case of a self-inflicted cement burn involving 75% TBSA. A 28-yr-old building worker attempted suicide by jumping into a cement mixer in a truck. Upon arrival at our burn centre, clinical examination revealed extensive burn (75% TBSA - 40% full-thickness) involving face, back, abdomen, upper limbs and circumferentially lower limbs, sparing the hands and feet. The patient was sedated, mechanically ventilated, and subjected to escharotomy of the lower limbs in the emergency room. The following day, the deep burns in the lower limbs were excised down to the fascia and covered with meshed allografts. Owing to probable intestinal and skin absorption of cement, metal toxicity was suspected and dialysis and forced diuresis were therefore initiated on day 3. The patient's clinical conditions gradually worsened and he died on day 13 from the multi-organ failure syndrome.
44 SCHOOL FIRE IN IRAN: SIMPLE ACTIONS SAVE LIVES
(Ostad Taghizadeh A., Mowafi H., Ardalan A. - Iran)
On December 5, 2012 a fire broke out in a primary school in Iran, causing injuries to 26 children and two deaths. The fire came from an oil stove. Rather than evacuate the classroom and use the fire extinguisher, the teacher attempted to remove the stove itself from the classroom. During this process an explosion occurred resulting in a haphazard attempt at evacuation. This tragedy highlights gaps in both the policy and practice of fire safety. From 2005 to 2012, Iran experienced six large school fires that led to 67 injuries and five deaths. Five events were related to oil stoves. About 30% of Iran's classrooms use oil stoves for heating during the winter with 3.4 million students and 150,000 teachers at risk. Iran's Ministry of Education has mandated that regular training of school personnel in fire safety measures should be organized but no safety officer is tasked to prepare and conduct this training. Instead, the task is delegated to the Fire Departments, which fall under municipal administrations; however, such departments do not exist in 93% of the rural areas of Iran. School fires are not unique to Iran. Similar tragic events have occurred in several middle-income countries (India, Kenya, Russia) over the last decade. This article presents an overview of school fires in Iran and proposes preventive strategies through a reform in policy making and practice, including education of students and school personnel along with regular drills, designation of a fire safety officer, and development of a countrywide school fire registry.
48 PRIMARY TRIAGE OF MASS BURN CASUALTIES WITH ASSOCIATED SEVERE TRAUMATIC INJURIES
(Atiyeh B., Gunn S. William A., Dibo S. - Lebanon)
A key aim in any mass disaster event is to avoid diverting resources by overwhelming specialized tertiary centers with minor casualties. The most crucial aspect of an effective disaster response is pre-hospital triage at the scene. Unfortunately, many triage systems have serious shortcomings in their methodologies and no existing triage system has enough scientific evidence to justify its universal adoption. Moreover, it is observed that the optimal approach to planning is by no means clear-cut and that each new incident involving burns appears to produce its own unique problems not all of which were predictable. In most major burns disasters, victims mostly have combined trauma burn injuries and form a heterogeneous group with a broad range of devastating injuries. Are these victims primarily burn patients or trauma patients? Should they be taken care of in a burn center or in a trauma center or only in a combined burns-trauma center? Who makes the decision? The present review is aimed at answering some of these questions.
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