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Volume XXIX |
Number 1 |
March 2016 |
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Summaries
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CLINICAL AND DEMOGRAPHIC FEATURES OF BURN INJURIES IN KARACHI: A SIX-YEAR EXPERIENCE AT THE BURNS CENTRE, CIVIL HOSPITAL, KARACHI
(Ali S.A., Hamiz-ul-Fawwad S., Al-Ibran E., Ahmed G., Saleem A., Mustafa D., Hussain M. - Pakistan)
Burn injuries are a leading cause of morbidity and mortality, with 195,000 deaths annually. This study was conducted to identify the demographics of burn victims and the effect of different variables on the outcome of their injuries. 4016 patients admitted to the Burns Centre, Civil Hospital Karachi from January 2006 to December 2011 were retrospectively analyzed. Demographics, burn injury details and their outcome were recorded in a pre-designed questionnaire. Injuries were categorized as: fire, chemical, scald or electrical. To estimate total body surface area (TBSA) burned in adults, the rule of nines was used. For children and infants, the Lund-Browder chart was employed. SPSS v16.0 software was used for analysis. Frequencies and percentages of all variables, and the measure of central tendencies and dispersion for continuous variables were calculated. Cross tabs were used to assess mortality. Mean age was 28.13 years. More than half of the cases (n=2337, 58.2%) were aged between 16-30 years. Labourers, housewives and students were the most commonly affected groups. Burn injuries by flame/fire and electricity were most common. Most cases were accidental, followed by suicide attempts and homicides. Mean percentage of TBSA affected was 35.49%. Mean duration of hospital stay was 16.45 days. 50.6% of the expired cases were females. The mean age of expired patients was 30.07 while for patients who survived it was 27.01 years. The outcome of burn injuries is related to various demographic factors. Female gender, increasing age, burn injuries following suicide attempts and greater surface area involvement predict poor outcome.
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OVERVIEW OF ETHNO-FOLKLORIC BURNS IN THE REPUBLIC OF SLOVENIA
(Stritar A., Brcic A., Drnovsek F., Malvasio V. - Slovenia)
The article describes typical folkloric- and ethnographic-related burns/scalds in Slovenia. All of the mentioned burns/scalds derive from the life of a nation, and are primarily a result of specific customs, traditions and activities carried out in a rural environment. Prolonged periods of lying on a hot tiled wood burner results in deep contact burns. The preparation work for pig slaughtering ('koline') is dangerous due to the large quantities of boiling water required for the slaughter process and meat production technology. Distilling spirits in an improvised domestic setting is another cause of burns/scalds, as the production of spirits is carried out in several stages with a high risk of burn trauma in the event of negligence. These types of burns/scalds occur in rural farming areas. Such injuries are most often ignored and patients, children excepted, do not seek medical help until later, after they have completed their activity. Due to aggressive thermal agents, these are deep burns that often require specialist surgical care with long-term treatment. Results are evaluated on the basis of a tenyear statistical and clinical experience. Incidence of the aforementioned burns is considerably lower today than it was in the past due to national prevention measures and new European legislation on energy and agriculture. In the future, we expect these distinctive burns/scalds to become a rarity.
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LA50 IN BURN INJURIES
(Seyed-Forootan K., Karimi H., Motevalian S.A., Momeni M., Safari R., Ghadarjani M. - Iran)
Burn injuries put a huge financial burden on patients and healthcare systems. They are the 8th leading cause of mortality and the 13th most common cause of morbidity in our country. We used data from our Burn Registry Program to evaluate risk factors for mortality and lethal area fifty percent (LA50) in all burn patients admitted over two years. We used multiple logistic regressions to identify risk factors for mortality. LA50 is a reliable aggregate index for hospital care quality and a good measure for comparing results, also with those of other countries. 28,690 burn patients sought medical attention in the Emergency Department, and 1721 of them were admitted. Male to female ratio was 1,75:1. 514 patients were under 15 years old. Median age was 25 (range: 3 months - 93 years). Overall, probability of death was 8.4%. LA50 was 62.31% (CI 95%: 56.57-70.02) for patients aged 15 and over and 72.52% (CI 95%: 61.01-100) for those under 15. In the final model, we found that Adjusted OR was significant for age, female sex, TBSA and inhalation injury (P < 0.05). LA50 values showed that children tolerate more extensive burns. Female sex, burn size, age and inhalation injury were the main risk factors for death. Authorities should pay special attention to these variables, especially in prevention programs, to reduce mortality and improve patient outcome. Children have better outcome than adults given equal burn size. Suicide rates are higher for women than men in our country.
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TIME FROM ACCIDENT TO ADMISSION TO A BURN INTENSIVE CARE UNIT: HOW LONG DOES IT ACTUALLY TAKE? A 25-YEAR RETROSPECTIVE DATA ANALYSIS FROM A GERMAN BURN CENTER
(Schiefer J.L., Alischahi A., Perbix W., Grigutsch D., Graeff I., Zinser M., Demir E., Fuchs P.C., Schulz A. - Germany)
Severe burn injuries often require specialized treatment at a burn center. It is known that prompt admission to an intensive care unit is essential for achieving good outcome. Nevertheless, very little is known about the duration of time before a patient is admitted to a specialized center after a burn injury in Germany, and whether the situation has improved over time. We retrospectively analyzed time from burn injury to admission to the burn intensive care unit in the Cologne-Merheim Medical Center - one of Germany's specialized burn centers - over the last 25 years. Moreover, we analyzed the data based on differences according to time of injury and day of the week, as well as severity of the burn injury. There was no weekend effect with regard to transfer time; instead transfer time was particularly short on a Monday or on Sundays. Furthermore, patients with severe burn injuries of 40-89% total body surface area (TBSA) showed the least differences in transfer time. Interestingly, the youngest and the oldest patients arrived at the burn intensive care unit (BICU) the fastest. This study should help elucidate published knowledge regarding transfer time from the scene of the accident to admission to a BICU in Germany.
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NUTRITION CHEZ LE BRÛLÉ
(Perro G. - France)
La nutrition est un challenge chez le brûlé, paradigme de l'agressé. Les points importants sont les apports entéraux précoces par sonde gastrique voire post pyloriques, la position proclive > 30°, la surveillance du transit et sa régulation par gastro ou entéro-kinétiques, la surveillance du poids, la quantification des apports avec supplémentation parentérale en cas de retard protéino énergétique. Chez l'enfant, l'adhésion à l'alimentation est difficile, de même que chez le senior, où une évaluation nutritionnelle initiale dépiste souvent une dénutrition préexistante. Les compléments alimentaires seront largement prescrits chez les patients de gravité intermédiaire. Les obèses bénéficieront d'un régime hypocalorique et hyperprotidique. Chez l'insuffisant rénal non dialysé il convient de limiter les apports en potassium. En cas brûlure périnéale, on peut proposer soit une constipation de courte durée, soit la mise en place d'un entéro-collecteur, les indications de colostomie étant devenues rares. Les apports entéraux sont difficiles à gérer en cas de décubitus ventral pour SDRA. Chez le brûlé grave de réanimation, l'accent doit plus être mis sur la qualité des nutriments que sur leur quantité. Les anciennes formules d'estimation calorique conduisaient à une surnutrition difficile à administrer et en général mal tolérée; la quantification mesurée par calorimétrie indirecte ou estimée par la formule de Toronto est bien plus adaptée. Plus récemment, l'instauration d'une immunonutrition (supplémentation en vitamines et oligo-éléments, glutamine, arginine, acide O 3 et contrôle raisonné de la glycémie) a été proposée pour réduire le stress oxydatif et l'inflammation provoqués par l'accident.
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GERMAN, EUROPEAN OR AMERICAN BURN GUIDELINES - IS ONE SUPERIOR TO ANOTHER?
(Paprottka F.J., Krezdorn N., Young K., Ipaktchi R., Hebebrand D., Vogt P.M. - Germany)
Adequate medical care of severe burn injuries requires special organizational infrastructure and high educational standards, with an appropriate number of health care professionals. Guidelines were written by the German Society for Burn Treatment (DGV), the European Burns Association (EBA) and the American Burn Association (ABA) to assist with the delivery of such care. Current DGV (2010), EBA (2013) and ABA (2001/2006/2008) guidelines are compared, focusing on similarities, differences, conciseness and completeness. This publication presents advantages and disadvantages of each of them. DGV guidelines outline understandable treatment recommendations for first aid measures, clinical procedures and wound care. Extensive rehabilitation guidelines with clearly defined indications and precise infrastructure requirements for a Burn Centre are stated. Negative aspects are the presence of multiple documents containing redundant and confusing information. EBA guidelines offer the most comprehensive treatment recommendations with multidisciplinary approaches. Overall, infrastructural requirements are weighted much higher than staff qualification demands - in contrast to ABA guidelines. However, lack of conciseness and complicated criteria regarding transfer of patients to a Burn Center - including imprecise indications for rehabilitation treatment - have to be mentioned as disadvantages. ABA guidelines have a clear focus on staff qualifications and easy-to-understand transfer criteria. Another focus is on detailed clinical procedures. However, these guidelines lack burn definition and precise treatment recommendations for rehabilitation. The reviewed guidelines provide standardized treatment recommendations for burn patients. Despite their usefulness, they all have weaknesses and discrepancies. Findings should be used to improve each of them.
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LA NÉCROLYSE ÉPIDERMIQUE TOXIQUE
(Mokline A., Rahmani I., Garsallah L., Tlaili S., Hammouda R., Gasri B., Messadi, A.A. - Tunisie)
La nécrolyse épidermique toxique (NET) ou syndrome de Lyell (SL) est une toxidermie de survenue imprévisible, grave et potentiellement mortelle, s'exprimant par des détachements épithéliaux cutanés et muqueux. Elle impose une prise en charge précoce des patients dans une unité de soins intensifs, au mieux dans un service de réanimation des brûlés, essentiellement symptomatique: analgésie, réanimation hydro-électrolytique, nutrition, pansements, prévention de l'infection. Le but de cette étude est de rapporter les données épidémiologiques, cliniques, thérapeutiques et évolutives des cas de SL observés dans le service de réanimation des brûlés de Tunis durant 9 ans, entre juillet 2001 et juillet 2009.
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HIGH-VOLTAGE ELECTRICAL BURNS DUE TO COPPER THEFT - CASE SERIES
(Braga M.J., Oliveira I., Egipto P., Silva A. - Portugal)
Electrical burns are among the most devastating trauma inflicted on the human body. These burns have a higher morbidity, length of stay and a much higher risk of amputation than any other type of burn. Electrical burns affect mostly young, working males because they are more frequently the result of a work accident. However, possibly due to the worldwide economic crisis, we are experiencing a new phenomenon: the theft of high-voltage copper wiring.
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CIVILIAN BLAST-RELATED BURN INJURIES
(Patel J.N., Tan A., Dziewulski P. - United Kingdom)
There is limited English literature describing the experience of a civilian hospital managing blast-related burn injuries. As the largest regional burn unit, we reviewed our cases with the aim of identifying means to improve current management. A 6-year retrospective analysis of all patients coded as sustaining blast-related burns was conducted through the unit's burns database. Medical case notes were reviewed for information on burn demographics, management and outcomes. 42 patients were identified. Male to female ratio was 37:5. Age range was 12-84 years, (mean=33 years). Total body surface area (%TBSA) burn ranged from 0.25% to 60%, (median=1%). The most common burn injury was flame (31/42, 73.8%). Gas explosions were the most common mechanism of injury (19 cases; 45.2%). 7/42 cases (16.7%) had full ATLS management pre-transfer to the burns unit. The Injury Severity Score (ISS) ranged from 0-43 (median=2). 17/42 (40.4%) patients required admission. 37/36 (88.1%) patients were managed conservatively of which 1 patient later required surgery due to deeper burns. 5/42 (11.9%) patients required surgical management at presentation and these were noted to be burns with >15% TBSA requiring resuscitation. One case required emergency escharotomies and finger amputations. All patients survived their burn injuries. Blast-related burn injuries are generally uncommon in the civilian setting. Following proper assessment, most of these cases can be deemed as minor injuries and managed conservatively. Improvement in burns management education and training at local emergency departments would provide efficient patient care and avoid unnecessary referrals to a burns unit.
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EVALUATION OF WHO ORAL REHYDRATION SOLUTION (ORS) AND SALT TABLETS IN RESUSCITATING ADULT PATIENTS WITH BURNS COVERING MORE THAN 15% OF TOTAL BODY SURFACE AREA (TBSA)
(Moghazy A.M., Adly O.A., Elbadawy M.A., Hashem R.E. - Egypt)
Intra-venous (IV) burn resuscitation is effective; nevertheless it has its disadvantages. WHO Oral Rehydration Solution (ORS) has shown high effectiveness in treating dehydration. WHO-ORS, with salt supplement, seems to be suitable for burn resuscitation, where IV resuscitation is not available, feasible or possible. The objective of the study was to evaluate acute phase efficacy and safety, as well as limitations and complications of burn resuscitation using WHO-ORS and salt tablets. This randomized controlled clinical trial was conducted in the Burn Unit, Suez Canal University Hospital, Ismailia, Egypt. The study group was given WHO-ORS (15% of body weight/day) with one salt tablet (5gm) per liter according to Sørensen's formula. The control group was given IV fluids according to the Parkland formula. Patients' vital signs and urine output were monitored for 72 hours after starting resuscitation. Both groups were comparable regarding age, sex, and percentage, etiology and degree of burns. For all assessed parameters, there were no major significant differences between the study group (10 cases) and control group (20 cases). Even where there was a significant difference, apart from blood pressure in the first hour of the first day, the study group never crossed safe limits for pulse, systolic blood pressure, urine output, respiratory rate and conscious level. WHO-ORS with 5gm salt tablets, given according to Sørenson's formula, is a safe and efficient alternative for IV resuscitation. It could even be a substitute, particularly in low resource settings and fire disasters.
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IMMEDIATE TANGENTIAL EXCISION ACCELERATES WOUND CLOSURE BUT DOES NOT REDUCE SCARRING OF MID-DERMAL PORCINE BURNS
(Macri L.K., Singer A.J., McClain S.A., Crawford L., Prasad A., Kohn J., Clark R.A.F. - USA)
Current evidence supports the use of excision to remove eschar from deep dermal and full-thickness burns. However, the role of excision of mid-dermal burns remains unclear. This study aimed to develop a porcine model that could produce reproducible middermal thermal burns that undergo tangential excision; and investigate the effects of immediate tangential excision (30 minutes postburn) on healing and scarring. An aluminum bar preheated in hot water (70°C) was applied for 20 or 30 s to produce a total of sixteen mid-dermal burns per pig on each of six pigs. Thirty minutes after burn creation, half of the burns were tangentially excised. Four partial- thickness wounds per pig were created as controls. Depth of burn injury (1 and 24 h), reepithelialization (7 and 10 d) and scar depth (28 d) were assessed microscopically. Total scar surface area was grossly evaluated on day 28. Exposure of porcine skin to a preheated aluminum bar at 70 °C for 20 or 30 sec resulted in reproducible mid-dermal burns, where immediate excision enhanced complete wound closure as judged by complete re-epithelialization, but did not reduce initial depth of injury, scar contraction and scar depth. Immediate surgical intervention is sufficient to enhance wound closure, but not to mitigate mid-dermal burn scar formation. This work provides a suitable animal model to evaluate novel therapies that may be used to inhibit burn progression, accelerate wound closure and decrease scarring, especially those therapies unable to penetrate burn eschar.
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TRAUMATISME DE LA MAIN PAR INJECTION A HAUTE PRESSION
(Mabchoure K., Diouri M., Bahechar N., Chlihi A. - Maroc)
Les traumatismes de la main par injection à haute pression sont des accidents relativement rares et souvent mal connus par le praticien. Les lésions qui dépendent du produit injecté et du site d'injection sont pourvoyeuses de séquelles esthétiques et fonctionnelles lourdes. Le traitement repose sur la chirurgie, l'antibiothérapie et la rééducation précoce et spécifique. Nous rapportons notre expérience ainsi qu'une revue de la littérature.
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MICROSURGERY "WITHOUT BORDERS": NEW LIMITS FOR RECONSTRUCTION OF POST-BURN SEQUELAE IN THE HUMANITARIAN SETTING
(Tocco-Tussardi I., Presman B., Cherubino M., Garusi C., Bassetto F. - Italy)
Post-burn contractures account for up to 50% of the workload of a plastic surgery team volunteering in developing nations. Best possible outcome most likely requires extensive surgery. However, extensive approaches such as microsurgery are generally discouraged in these settings. We report two successful cases of severe hand contractures reconstructed with free flaps on a surgical mission in Kenya. Microsurgery can be safely performed in the humanitarian setting by an integration of: personal skills; technical means; education of local personnel; follow-up services; and an effective network for communication.
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REVERSE-FLOW ANTEROLATERAL THIGH PERFORATOR: AN AD HOC FLAP FOR SEVERE POST-BURN KNEE CONTRACTURE
(Ismail H.A., El-Bassiony L.E. - Egypt)
We evaluate function outcomes of the reverse-flow ALT perforator flap to reconstruct severe post-burn knee contracture. Between October 2012 and December 2014, 10 patients with severe post-burn knee contracture were subjected to reconstruction with 10 ipsilateral reversed-flow ALT perforator flaps. All the patients were male. Ages ranged from 15 to 47 years (mean = 32 years). Time from burn injury to patient presentation ranged from 2-8 months. All patients demonstrated post-burn flexion contracture of the knee joint, ranging from 35 to 75 degrees. Flap sizes ranged from 8×16 to 12×26 cm. The flaps and skin grafts were carried out without major complications. Only minor complications occurred, such as transient, mild congestion immediately after inset in two flaps. Two flaps developed superficial necrosis at the distal edge. One case sustained partial skin graft loss due to haematoma. One case complained of skin hyperpigmentation and hypertrophic scars around the graft. Secondary debulking procedures were required in two cases. The entire donor sites were closed by partial thickness skin graft with acceptable appearance, except one case that was closed primarily. Eight out of ten patients (80%) demonstrated gradual improvement in range of knee motion after a specialized rehabilitation program. Two patients (20%) did not get back full range of motion. RALT perforator flap is the cornerstone for the reconstruction of soft-tissue defects around the knee with acceptable aesthetic and functional results provided that the following items are fulfilled: inclusion of muscle cuff around the pedicle, the pivot point, prevention of pedicle compression after transfer and early surgical intervention on the post-burn knee contracture.
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