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Volume XXVIII |
Number 1 |
March 2015 |
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Summaries
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ABDOMINAL COMPARTMENT SYNDROME (ACS) IN A SEVERELY BURNED PATIENT
(Kollias S., Stampolidis N., Kourakos P., Mantzari E., Koupidis S., Tsaousi S., Dimitrouli A., Atiyeh B., Castana O. - Greece)
Abdominal compartment syndrome (ACS) occurs when increasing intra abdominal-pressure (iAp) reduces blood flow to abdominal organs. This results in impairment of pulmonary, cardiovascular, renal, hepatic, central nervous system and gastro-intestinal (gi) function, causing multiple organ dysfunction syndrome and death. The significant prognostic value of elevated intra-abdominal pressure has prompted many intensive care units to adopt measurement of this physiologic parameter as a routine vital sign in patients at risk. ACS generally occurs in patients who are critically ill due to any of a wide variety of medical and surgical conditions. it has been recently described as a rare complication of burn injury. it is fundamental to: 1) recognize iAp and ACS; 2) resuscitate effectively; and 3) prevent the development iAp-induced end-organ dysfunction and failure. We present our recent experience with one patient suffering from ACS secondary to burn injury and the physiologic results of abdominal wall escharotomy.
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THE CLINICAL EFFICACY OF DIPHOTERINE® IN THE MANAGEMENT OF CUTANEOUS CHEMICAL BURNS: A 2-YEAR EVALUATION STUDY
(Zack-Williams S.D.L., Ahmad Z., Moiemen N.S. - United Kingdom)
Diphoterine® is an amphoteric irrigating agent for the treatment of chemical burns and rapidly neutralises both acids and alkalis faster than water alone. Diphoterine® is widely used as a first aid agent in a wide range of industries globally. This is a retrospective review of the clinical use of Diphoterine® on chemical burns in an adult tertiary referral burn centre, often with a delay of several hours after the injury. patients admitted with chemical burns within 24 hours of the incident with an abnormal wound pH or in pain, were treated with Diphoterine® spray. Over a 32-month period, 1,875 burn referrals were admitted of which 131 (7%) were chemical burns. Diphoterine® was used in 47 patients (36%). The male to female ratio for the 131 patients was 4:1. Alkaline burns were the commonest (55%). patients who received Diphoterine® were significantly younger (38 vs 43 years; p=0.05) and presented earlier (0.5 vs 2.55 days; p=0.004). There was a significant change in the wound pH pre- and post-application of Diphoterine®, compared to patients who were treated with water irrigation only, with a pH change of 1.076 vs 0.4 (p <0.05). There was no significant difference in the time to healing, the length of hospital stay, or need for surgery. in conclusion, based on our retrospective cohort, Diphoterine® could be a valuable tool for use in hospital settings to neutralise both alkaline and acid burns.
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BACTÉRIOPHAGES ET PHAGOTHÉRAPIE : UTILISATION DE VIRUS NATURELS POUR TRAITER LES INFECTIONS BACTÉRIENNES
(Ravat F., Jault P., Gabard J. - France)
L'utilisation des bactériophages, prédateurs naturels des bactéries, est une technique pionnière efficace de lutte contre les infections bactériennes. Tombée dans l'oubli depuis un demi-siècle du coté occidental de l'ex-rideau de fer, elle fait toujours partie de l'arsenal thérapeutique des pays de l'ex-Europe de l'Est, au point de constituer une arme de choix dans la politique de santé publique de ces pays. l'émergence de bactéries multirésistantes et le risque de revenir à l'ère pré-antibiotique ont fait ressortir la phagothérapie de l'oubli injuste auquel elle avait été confinée. la biologie et la place du bactériophage dans la nature sont décrites ici. les tenants et les aboutissants de la phagothérapie et les conditions de son retour sur le devant de la scène sont explicitées.
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INFECTIONS FONGIQUES DES BRÛLÉ : REVUE
(Arnould JF., Le Floch R. - France)
Les infections fongiques locales ou générales sont souvent d'une extrême gravité chez les brûlés. les brûlés combinent de nombreux facteurs de risque à une immunodépression induite par la brûlure. les infections de plaies sont le fait des genres Candida, Aspergillus et des agents de mucormycoses. Ces deux derniers cas sont à l'origine de lésions particulièrement sévères. leur diagnostic repose sur la biopsie cutanée avec examens mycologique et anatomopathologique. le traitement est essentiellement chirurgical, associé à une antibiothérapie adaptée. les septicémies sont le fait de levures, essentiellement du genre Candida. le diagnostic en est difficile dans le contexte des brûlés et repose souvent sur une forte suspicion clinique. leur traitement repose sur les échinocandines et plus secondairement sur le fluconazole
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OPTIMAL TIMING FOR BURNED HANDS IN CHILDREN
(Ionita D., Enescu D., Giuvelea S., Stoicescu S., Mitrache P. - Romania)
Hand burns in children are frequent, severe, and require adequate treatment. A fundamental, though problematic aspect of this treatment is the assessment of the burn depth as this determines the surgical strategy. From a retrospective study of 369 hand burns admitted to our clinic, we were able to identify some patterns. A total of 14.91% required surgery, with varying etiology among these patients. Differences were also noticed in the number of days post-burn prior to surgical intervention. The patterns revealed by our results are reviewed in order to improve therapeutic strategy.
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TRAITEMENT DES SÉQUELLES DE BRÛLURES DE LA MAIN DANS LES PAYS À RESSOURCES LIMITÉES ; NOTRE EXPÉRIENCE EN RÉPUBLIQUE DÉMOCRATIQUE DU CONGO
(Kibadi K., Moutet F. - République Démocratique du Congo)
Les séquelles de brûlures de la main sont encore fréquentes dans les pays à ressources limitées. Trente-deux patients, représentant 38 mains, ont été admis et traités, entre le 1er décembre 2010 et le 1er mai 2014 aux Cliniques Universitaires de Kinshasa en république Démocratique du Congo (rDC). nous avons observé 22 patients (69 %) dans le groupe de jeunes (patients âgés de moins de 18 ans), et 10 patients (31 %) chez les adultes (18 à 59 ans). Aucun patient dans le groupe de seniors (60 ans et plus) n'a été observé. Dans le groupe de jeunes, la tranche d'âge de 1 à 5 ans a été la plus atteinte avec 13 malades (40 %). l'accident à la maison était le plus fréquent (72 %). le mécanisme de la brûlure était le plus souvent thermique par flammes (51 %) ou par liquide chaud (34 %). les rétractions et brides sont les lésions le plus observées (84 %). la rétraction dorsale globale « main en griffe» est observée chez 40 % de patients traités, associée à des cicatrices hypertrophiques et chéloïdiennes dans 84 % de cas. Chez les 32 mains traitées chirurgicalement, des excision-greffes ont été réalisées dans 43,7 %, des lambeaux locaux dans 43,7 % et des lambeaux à distance dans 12,5 % de cas. A la sortie de l'hôpital, 84 % de « bons » résultats ont été observés. le suivi a été de 18 mois. le traitement des séquelles de brûlures de la main est possible dans ces pays, exemple de la rDC. Mais les défis à surmonter dans ces pays sont nombreux : la faible accessibilité aux techniques actuelles de la chirurgie plastique, la prise en charge initiale inadéquate des brûlures, la pauvreté.
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MICROSURGERY IN THE BURN POPULATION - A REVIEW OF THE LITERATURE
(Ibrahim A.E., Skoracki R., Goverman J.G., Sarhane K.A., Parham C.S., Abu-Sittah G., Kaddoura I., Atiyeh B.S. - Lebanon)
The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.
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MANAGEMENT OF COMPLEX PEDIATRIC BURN SCARS IN A HUMANITARIAN COLLABORATION
(Bassetto F., Staffieri A., Reho F., Facchin F., Shehata J., Maged D., Tiengo C. - Italy)
Burn scars still represent a challenge to the reconstructive surgeon. Their management requires a specific expertise and set up involving the possibility of long term rehabilitation and follow up. Cases encountered in humanitarian missions present additional issues. Often the local environment is not suitable for an appropriate treatment plan, requiring the case to be transferred to a foreign country for surgical care as part of an integrated international and multidisciplinary management. We present the case of a three year-old patient injured in a bomb explosion during the Arab Spring and suffering from severe scar contracture limiting thoracic and upper limb movement. After initial consultation at distance, transfer to our country was organized and an intensive surgical and rehabilitative program was carried out over three months. After five months, the patient returned to his home country where a supportive network had been set up for continued rehabilitation, ensuring follow up for over a year and ultimate success.
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AFFLUX MASSIF DE BRÛLÉS : LA DOCTRINE FRANÇAISE DE TRIAGE EN TEMPS DE PAIX
(Bargues L., Fall M.M. - France)
les situations de catastrophe impliquant un grand nombre de brûlés peuvent survenir à tout moment après un incendie, une attaque terroriste, une explosion industrielle ou un accident de transport. les différentes sociétés internationales de brûlologie ont publié des recommandations sur la préparation à l'afflux massif de brûlés. la Société Française d'Étude et de Traitement des Brûlés (SFETB) propose le triage des victimes selon la Surface Cutanée Brûlée (SCB), l'inhalation de fumées et les lésions traumatiques associées. Ce plan cherche à catégoriser les victimes et à attribuer à chaque patient un lit adapté à ses besoins thérapeutiques (centre des brûlés, réanimation médicale ou chirurgicale, service d'urgences, chirurgie, poste de triage). les Services d'Aide Médicale Urgente (SAMU) sont au coeur du dispositif : premiers soins, poste Médical Avancé (pMA), régulation, triage et transport, renfort en matériel dans l'hôpital de proximité. Un plan catastrophe pour brûlés doit être adapté aux capacités hospitalières du pays.
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TRANSPORT AÉRIEN LONGUE DISTANCE DES BRÛLÉS GRAVES : REVUE DE LA LITTÉRATURE ET APPLICATION PRATIQUE
(Leclerc T., Hoffmann C., Forsans E., Cirodde A., Boutonnet M., Jault P., Tourtier J.-P., Bargues L., Donat N. - France)
Les brûlés graves nécessitent une prise en charge multidisciplinaire dans des centres hautement spécialisés. la rareté de ces centres impose souvent le transport aérien médicalisé longue distance. Cependant, il y a peu de données publiées sur ces transferts. Dans cette mise au point, pour optimiser la prise en charge des brûlés dès qu'un transport aérien est décidé ou même seulement envisagé, nous proposons d'extraire de cette littérature limitée des principes simples s'appuyant aussi sur l'expérience pratique du Service de Santé des Armées françaises. nous décrivons d'abord comment les contraintes aéronautiques peuvent affecter le transport de brûlés graves à bord d'aéronefs. nous abordons ensuite la régulation de ces missions, en analysant les risques associés au transport aérien des brûlés graves et leurs implications sur les indications, la chronologie et les modalités du transport. Enfin, nous développons la conduite de la mission, comprenant la préparation du matériel et des consommables avant le vol, l'évaluation et la mise en condition du patient avant l'embarquement, et la poursuite de la prise en charge en vol.
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SATURDAY NIGHT BURNS: AN INCREASING PROBLEM?
(Bollero D., MalvasioV., Gangemi E.N., Giunta G., Collard B., Stella M. - Italy)
In italy the economic crisis has caused changes in behavior in daily as well as leisure activities. For instance, night clubs have changed both their scenography and what they can offer. From simply providing a place to dance, they can now offer more complex scenography with spectacular fireworks and lit cocktails. While this can be amazing for all of us it can also be another cause of burn injuries. We conducted a retrospective study of all burns patients admitted to the Accident and Emergency Department at CTO Hospital in Turin from 2009 to 2013, after a night clubbing. A total of five patients were identified with an average age of 20 years old: four were burned by flaming cocktails and one was burned by a firework. Two received outpatient treatment, while orotracheal intubation and admission were needed for three, and two required surgical debridement and resurfacing with split skin graft. All patients had permanent sequelae caused by pathologic scarring and/or dyschromia. Our findings show that the risk of burn injuries is higher at weekends, mainly in summer, if all correct safety procedures are not followed. Meanwhile it is important to highlight that the promotion of inappropriate behavior at night clubs during firework displays and the passing of flaming cocktails should be avoided.
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MAJOR BURN INJURIES ASSOCIATED WITH CHRISTMAS CELEBRATIONS: A 41-YEAR EXPERIENCE FROM SWITZERLAND
(Rohrer-Mirtschink S., Forster N., Giovanoli P., Guggenheim M. - Switzerland)
In Switzerland it is customary to light candles on Christmas trees and advent wreaths. This tradition leads to an increased risk of home fires. We reviewed the records of patients who sustained burn injuries from a lit Christmas tree or advent wreath during the Christmas holidays between January 1971 and January 2012. We treated 28 patients and observed 4 fatalities (mortality rate: 14%). 61% of the patients were male, 39% were female. The mean abbreviated burn severity index (ABSi) was 6.5 points in the group of the survivors and 10.8 points in the group of the non-survivors. The mean total body surface area burned (TBSA) for survivors was 18.9%, with 14.1% having full thickness burns; for the non-survivors the mean TBSA was 45.2%, with 38% having full thickness burns. The Mann-Whitney U-test showed a significant difference between the survivors and the fatalities concerning the mean total and full thickness burned body surface area (p value 0.009 and 0.012). More than sixty percent of the fires occurred in January and the most severe accidents were seen after January 4th. Despite Christmas decoration-associated fires being relatively uncommon, they tend to cause more serious injuries than regular household fires. We recommend that in countries where it is customary to set up flammable Christmas decorations, state-issued information pamphlets with instructions on fire safety conduct should be distributed.
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