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Volume XXX |
Number 4 |
December 2017 |
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Summaries
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BURNS IN THE THIRD WORLD: AN UNMET NEED
(Stokes M.A.R., Johnson W.D. - Switzerland)
Burns continue to present a significant public health problem, resulting in scores of preventable deaths and disability every year. The burden of burns disproportionately falls to the world's poor residing in low and middle-income countries (LMICs). Those who are burnt require timely access to acute burns management, including definitive surgical care. The current lack of access to safe and affordable surgical care with anaesthesia worldwide means that some 5 billion people do not have access to acute burns management, including definitive surgical care for burns, when needed most. Major limitations to access to burn care at healthcare facilities in LMICs include a lack of appropriately trained staff (including surgeons), appropriate equipment and resources. Burn prevention measures have been successful in reducing the incidence of burns and deaths in many developed countries, however there is currently a paucity of robust understanding of what works in LMICs to prevent burns. A combined effort to implement proven burn prevention strategies and address the unmet need for access to safe and affordable surgical care with anaesthesia is required to reduce the global burden of burns that still exists.
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| 247 |
THE EPIDEMIOLOGY OF BURNS IN BASRA, IRAQ
(Al-Shamsi M., Othman N. - Iraq)
Burn injuries are often seen among the paediatric population. Mortality from burn injuries is high in developing countries. Poor facilities and poverty contribute to this. A look at the epidemiology of burn injuries among children from this part of the world will therefore serve as a means for developing programs for burn injury prevention. A retrospective review of burn injuries among the paediatric population was conducted. The aim was to outline common aetiologies, sex predisposition and sites of injury with a view to recommending possible ways of preventing these injuries. A total of 148 children sustained burn injuries during the period under study. There were 85 (57.4%) boys and 63 (42.6%) girls. Scald was the most common cause of injury, observed in 127 (85.8%) children, followed by flame burn in 18 (12.2%), chemical burn in 2 (1.4%), and friction burn in 1 (0.68%). Almost all of the injuries (144, 98%) occurred at home. Sources of heat were hot water, which caused injury in 109 (73.6%) children, and hot oil, hot soup and hot soya milk which were responsible for 7 (4.7%), 7 (4.7%) and 3 (2.0%) cases, respectively. Other sources were kerosene explosion (7, 4.7%), burning firewood (1, 0.6%) petrol explosion (5, 3.4%), candlelight (3, 2.0%), hot ashes (1, 0.6%), soot (1, 0.6%), burned house, chemicals and friction (1, 0.6%). Preventive methods are suggested based on aetiologies, and include education and certain precautions in the home environment. These will reduce burn injuries and associated morbidity and mortality in developing countries.
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| 250 |
EPIDEMIOLOGY AND CLINICAL PATTERN OF PAEDIATRIC BURNS REQUIRING HOSPITALIZATION IN SARAJEVO CANTON, BOSNIA AND HERZEGOVINA, 2012-2016
(Zvizdic Z., Becirovic K., Salihagic S., Milisic E., Jonuzi A., Karamustafic A. - Bosnia and Herzegovina)
We first aimed to investigate the epidemiological characteristics and clinical pattern of hospitalized paediatric burn patients in Sarajevo Canton. Second, we aimed to determine the targets for the paediatric burn prevention program. This descriptive retrospective study was carried out to analyse the demographic, etiologic and clinical data of 73 hospitalized paediatric burn patients in Sarajevo Canton over a 5-year period from January 1, 2012 to December 31, 2016. The differences between various groups were evaluated using the chisquare test. During the course of the study, 73 paediatric burns (37 boys and 36 girls; ratio 1:0.97) were hospitalized. The overall mean age was 3.0 ± 2.9 years (range: 3 months to 12.5 years). The mean total body surface area burned was 8.4 ± 8.3%. The most common causes of burns in children were scald injuries (84.9%) followed by contact with a hot object (9.6%). No children were found to have burns caused by chemicals or electricity. A total of 97.3% of paediatric burn injuries occurred at home (p<0.001), and almost all were preventable. Although the most burns were recorded in the spring months (35.6%), there was no significant seasonal variation in burns (p = 0.199). Average length of hospital stay (LOS) was 16.32 ± 12 days (range: 1 to 65 days). The findings of the current study revealed that the main cause of paediatric burns was scald occurring at home. These data can contribute to the development of a prevention program to protect the paediatric population from burns.
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| 256 |
BURN INJURIES FROM THE LONDON SUICIDE BOMBINGS: A NEW CLASSIFICATION OF BLAST-RELATED THERMAL INJURIES
(Gille J., Dietz A., Taha H., SablotzkiA. - Germany)
The present study examined the effectiveness of an automated systemic inflammatory response syndrome (SIRS)-based alarm system for the early detection of sepsis in adult burn patients. In addition, the relevance of the sepsis criteria from the American Burn Association (ABA) and the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) for this patient group was determined. In this prospective observational study, we included 41 consecutive patients who were admitted to our burn ICU within a one-year period. SIRS alarms were calculated for these patients according to predefined criteria using the PREDEC ALARM automated alarm system and alarms generated according to ABA criteria and daily Sequential Organ Failure Assessment (SOFA) results. The alarms were not visible to the treating doctors and nurses. The alarms identified were related to episodes of sepsis with positive blood cultures. Twenty-one sepsis events were recorded in 41 patients. The receiver operating characteristic (ROC) curve revealed an area under the curve (AUC) of 0.72 for alarms using 2 SIRS criteria, 0.77 for 3 SIRS criteria, and 0.61 for 4 SIRS criteria. AUC values of 0.53 and 0.59 were calculated for the ABA criteria and Sepsis-3 definition, respectively. An alarm system using 3 SIRS criteria proved to be suitable for the early detection of sepsis in burn patients. The frequent number of false alarms requires further refinement of the alarm system. Based on the results of our study, the ABA criteria and the Sepsis-3 definition provide no advantages over the SIRS criteria in the early diagnosis of sepsis after burn injury.
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| 261 |
TOXIC EPIDERMAL NECROLYSIS IN A FEMALE WITH METASTATIC BREAST CANCER TREATED WITH VINORELBINE
(Bazine A., Fetohi M., Namad T., El Benaye J., Ennouhi M.A., Mahfoud T., Ichou M. - Morocco)
Vinorelbine is an anticancer agent with high clinical efficacy for the treatment of metastatic breast cancer. Toxic epidermal necrolysis is a rare but serious cutaneous adverse reaction associated with drug therapy. We hereby present a case report of a patient with metastatic breast cancer, treated with vinorelbine, who developed toxic epidermal necrolysis. To the best of our knowledge, ours is the second case report describing this exceptional dermatologic emergency associated with vinorelbine. In June 2014, a 33-year-old female was treated for localized breast cancer. In December 2016, a brain magnetic resonance imaging revealed cerebral and cerebellar recurrence of the breast cancer. Whole brain radiation therapy was administered and treatment with vinorelbine was subsequently initiated. On day 3 of the first cycle of chemotherapy, she presented a general malaise and an itchy rash with conjunctivitis, oral ulcers and diffuse alopecia. The clinical diagnosis was toxic epidermal necrolysis due to vinorelbine. The patient was transferred to the burn unit. Treatment with intravenous steroids, topical steroids and desloratadine was initiated. She subsequently developed Staphylococcus aureus bacteremia and died of multi-organ failure. Toxic epidermal necrolysis is an extremely rare, acute hypersensitivity reaction involving the skin and mucous membranes. Features more suggestive of toxic epidermal necrolysis are acute onset and rapid worsening of painful lesions of the skin and mucous membranes. Specific treatment with active interventions should be practiced in the context of an international and multicentre clinical study in order to give sufficient power for such trials in this rare disease.
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| 264 |
ASPECTS CLINIQUES ET THÉRAPEUTIQUES DES BRÛLURES PAR BRASERO TRADITIONNEL
(Bensaida L., Sabur S., Baya S., Mazouz S., Gharib N., Abbassi A. - Maroc)
Le brasero traditionnel reste un moyen de cuisson et de chauffage pour des milliers de familles, dans des zones rurales enclavées au Maroc. De la simple brûlure par bref contact accidentel jusqu'aux carbonisations des membres, ces brûlures sont d'autant plus graves qu'elles sont secondaires à des pertes de connaissance dans le cadre de crises d'épilepsie ou d'intoxication au monoxyde de carbone. Les séquelles sont lourdes dans les formes associées à des pertes de connaissance, essentiellement à cause du retard de prise en charge et de la non-observance des protocoles thérapeutiques par des malades de bas niveau socio économique.
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| 268 |
ELECTRICAL BURNS: A RETROSPECTIVE ANALYSIS OVER A 10-YEAR PERIOD
(Brandão C., Vaz M., Brito I.M., Ferreira B., Meireles R., Ramos S., Cabral L. - Portugal)
Although electrical burns have a rather low incidence, they are considered one of the most devastating injuries. The aim of this retrospective study was to analyse specific aspects of electrical injuries and to delineate a prevention strategy. A retrospective analysis of medical records of all the patients admitted to our Unit with electrical burns over a 10-year period (2006/01/01-2015/12/31) was undertaken. Demographic data, mechanism of injury and electric current voltage, total burn surface area (TBSA), location and depth of burns, acute complications, surgical interventions and length of hospital stay (LOS) were analysed. Out of 1695 burn patients admitted to our Unit, 99 subjects (5.84%) suffered electrical burns. 97% of these patients were male. The mean age was 38.3±13.7years and mean TBSA was 11.9%±13.2%. The mechanism of injury was occupational in 75 cases. Injuries were classified as low-voltage burns (24.2%), highvoltage burns (30.3%) and flash burns (45.5%). TBSA (p=0.014), mean LOS (p=0.002) and serum creatinine kinase levels (p<0.001) were significantly higher in patients with high-voltage injury in comparison to low-voltage injury, as well as the incidence of escharotomy/ fasciotomy (p=0.049) and flap surgeries (p=0.004). Although there was a higher incidence of amputations in this group (16.7% vs. 12.5%), the difference was not statistically significant (p=0.487). The high prevalence of electrical burns in males and workers emphasizes the need to review occupational safety regulations. Educational efforts regarding potential hazards of electricity and reinforcing compliance with safety measures are essential to avoid these injuries.
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| 272 |
LA MAIN DE PRESSE: UNE BRÛLURE PAS COMME LES AUTRES
(Ejjiyar M., El Amrani M.D., Benchamkha Y., Ettalbi S. - Maroc)
Les brûlures du membre supérieur dues au contact avec une presse chaude associent à l'atteinte thermique un traumatisme par compression de sévérité variable. Elles sont rares, surviennent le plus souvent dans le cadre d'accidents de travail suite à une erreur de manipulation et occasionnent des lésions graves multi-tissulaires imposant une prise en charge pluridisciplinaire urgente. Leur retentissement psycho-social est considérable, d'autant plus qu'elles touchent une population jeune.
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| 275 |
PREDICTORS OF INHALATION BURN INJURY USING FIRE SITE INFORMATION
(Kaneko T., Tanaka H., Yamada S., Kitada M., Sakurai T., Harada M., Kimura F., Takahashi T., Kasaoka S. - Japan)
Inhalation burn injury (IBI) is a risk factor for mortality in burn patients. However, it is difficult to diagnose IBI using traditional physical examination alone, especially in prehospital settings. Therefore, facial burn patients are usually treated for suspected IBI. In the present study, we investigated whether fire site information could predict IBI as an alternative to traditional physical examination. This retrospective single-centre analysis involved 27 facial burn patients with suspected IBI who were admitted between 2014 and 2016. The patients were divided into two groups (IBI and non-IBI) according to bronchoscopy findings. Fire site information was compared between the two groups. The IBI (n = 13) and non-IBI (n = 14) groups were compared. Domestic fire was more frequent in the IBI group (69% vs. 29%, P = 0.035). The IBI group included one patient with carboxyhemoglobin ?10% on admission. Prehospitalization fire site information, particularly domestic fires, might predict IBI in facial burn patients.
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| 278 |
OEDÈME PULMONAIRE LÉSIONNEL PAR INHALATION DE VAPEURS D'ACIDE PHOSPHORIQUE TRAITÉ PAR VNI
(Siah S., Nakkabi I. - Maroc)
Les brûlures par phosphore blanc sont des brûlures mixtes, essentiellement thermiques mais également chimiques. Le caractère très particulier de la prise en charge de ce type de brûlure mérite d'être rappelé. La toxicité systémique est redoutable par l'hypocalcémie qui entraine des troubles du rythme cardiaque. On peut aussi observer des complications respiratoires par inhalation de vapeurs d'acide phosphorique pouvant se compliquer d'oedème aigu pulmonaire lésionnel. Nous rapportons une observation d'oedème pulmonaire lésionnel par inhalation de vapeurs d'acide phosphorique.
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| 281 |
INFECTIOUS COMPLICATIONS IN ADULT BURN PATIENTS AND ANTIMICROBIAL RESISTANCE PATTERN OF MICROORGANISMS ISOLATED
(Zampar E.F., Anami E.H.T., Kerbauy G., Queiroz L.F.T., Carrilho C.M.D.M., Cardoso L.T.Q., Grion C.M.C. - Brazil)
The objective of this study was to analyze the incidence of hospital acquired infections (HAIs) in burn patients, and to determine the principle infection sites and the sensitivity profile of the microorganisms to antimicrobials. This is a retrospective cohort study, conducted in a specialized centre for the treatment of burns from January 2009 to December 2013. The sample consisted of 404 patients, divided into two groups: the first group comprised 142 patients without infection, and the second group was made up of 262 patients who had acquired HAIs. There was a predominance of males in both groups. Mean age of the patients without infection was 37 years (SD 14.89), and 38 years (SD 15.78) for the patients with HAIs. Of the 523 infections observed in this study, pneumonia was the most frequent with 216 (41%) cases, followed by urinary tract infections with 137 (26%) episodes. The pathogens identified were Acinetobacter baumannii (93, 40%), Pseudomonas aeruginosa (50, 21%) and Klebsiella (pneumoniae/oxytoca) (23, 10%) and were resistant to most common antimicrobials. In the study population, no pathogens resistant to vancomycin were found. The present study describes high rates of infection in burn victims. Pneumonia was the most frequent site of infection, followed by urinary tract infections caused respectively by non-fermenting bacteria with a high frequency of antimicrobial resistance.
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| 286 |
UTILISATION D'UNE SOLUTION POLYAMPHOTÈRE LORS DE LÉSIONS ET BRÛLURES CHIMIQUES OCULAIRES CUTANÉES ET BUCCALES. EFFET SUR LA DOULEUR DE LA DIPHOTÉRINE®
(Fortin J.L., Bodson L., Fontaine M., Depil-Duval A., Paulin P., Bitar M.P., Ravat F., Macher J.M., Hall A. - France)
Les solutions polyamphotères de lavage (SPL) sont utilisées depuis plusieurs années, principalement dans les industries chimiques, lors de projections oculaires et/ou cutanés de produits chimiques basiques ou acides. Nous présentons une étude multicentrique avec recueil de 37 observations d'utilisation de solution polyamphotère de lavage dans ce contexte. La majorité des accidents sont professionnels (56,75% des cas). Nous avons observé 23 atteintes oculaires isolées (9 atteintes bilatérales, 14 unilatérales), 9 atteintes cutanées isolées, 4 atteintes mixtes oculaires et cutanées et 1 atteinte buccale. Pour les 27 atteintes oculaires (isolées ou mixtes) une douleur est retrouvée dans 20 cas, un blépharospasme dans 4 cas, une hyperhémie conjonctivale dans 15 cas, un oedème palpébral dans 2 cas et une baisse d'acuité visuelle avec une vision floue dans 7 cas. Parmi les 13 atteintes cutanées nous avons observé des lésions cutanées profondes dans 2 cas et des lésions superficielles dans 11 cas. L'intensité initiale de la douleur variait de 3 à 10 avec une moyenne 6,29 +/- 2,74. L'EVA moyenne après SPL était de 1,47 +/- 1,73. Une application de SPL permet de réduire l'intensité de la douleur, qui témoigne de l'action délétère de l'agent chimique. Elle permet de réduire l'incidence des séquelles, à condition que son utilisation préhospitalière et hospitalière soit précoce.
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PRISE EN CHARGE D'UNE ASYSTOLIE AU COURS D'UNE GREFFE DERMO-ÉPIDERMIQUE DES DEUX MEMBRES SUPÉRIEURS
(Siah S., Aissa M. - Maroc)
Nous rapportons l'observation d'une patiente brûlée grave qui a présenté une asystolie au cours d'une greffe dermo-épidermique des deux membres supérieurs. Le saignement per-opératoire, l'hypovolémie et l'hypothermie sont à l'origine de cette asystolie. Nous rappelons la prise en charge d'un arrêt cardio-circulatoire au bloc opératoire au cours d'une chirurgie du brûlé grave.
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| 296 |
ALTERNATIVE A LA GREFFE DE PEAU POUR LA COUVERTURE DES BRÛLURES PROFONDES DE LA FACE DORSALE DE LA MAIN EN AIGU: REVUE DE LA LITTÉRATURE
(Alvo R., Serror K., Bern R., Chaouat M., Mimoun M., Boccara D. - France)
Les mains sont les zones les plus fréquemment touchées en cas de brûlure et sont impliquées dans environ 80% des cas. En raison de la finesse de la peau et de la localisation très superficielle et immédiatement sous-cutanée des structures nobles, la face dorsale de la main est une zone nécessitant une couverture optimale afin de conserver un maximum de mobilité articulaire et d'amplitude de mouvement. L'objectif de cet article est de détailler les alternatives thérapeutiques à l'excision-greffe dans les cas de brûlures profondes de la face dorsale de la main et d'en préciser les indications. Nous avons recherché les articles référencés sur PubMed et étudié tous les articles originaux relatifs à la prise en charge en aigu des mains profondément brûlées et les différentes techniques de couvertures (dermes artificiels et lambeaux). Nous avons exclu les articles traitant uniquement de couverture par greffe de peau, ainsi que les articles de prise en charge secondaire (au-delà d'un mois) dans le cadre de séquelles et reconstruction. Cent-seize articles ont été trouvés et vingt ont été sélectionnés. Les alternatives à la greffe de peau mince pleine sont les dermes artificiels (Alloderm®, Matriderm®, Integra®) et les lambeaux. En présence de zones donneuses immédiatement utilisables, on privilégiera la combinaison Matriderm® /greffe de peau mince pleine. En l'absence de zones donneuses, on utilisera l'Integra®. En cas d'exposition franche des structures nobles et sous-sol douteux, les lambeaux pourront être discutés (cross-arm, Colson modifié).
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EARLY FREE FLAP RECONSTRUCTION OF BLAST INJURIES WITH THERMAL COMPONENT
(Bakhach J., Abou Ghanem O., Bakhach D., Zgheib E. - Lebanon)
Modern warfare has seen advances in both weaponry and personnel protective material, thus allowing for better survival of injured individuals. As a result, the medical system is faced with an increasing number and diversity of non-life threatening wounds, to the extremities especially, sustained by multiple mechanisms. These wounds have a thermal injury component regardless of the mechanism, and there is often a delay in them being definitively treated, thus affecting final cosmetic and functional outcomes. Fourteen patients presented to our institution after sustaining blast injuries of different etiologies. Time of admission was between 0-10 days, and time of microvascular reconstruction after initial serial debridement was between 5-28 days. All patients were found to be infected with multiple organisms upon admission. Five patients were reconstructed with free vascularized skin flaps, three with osseous and osseocutaneous free flaps, four with free latissimus dorsi muscle flaps and two by toe-to-hand transfer. The follow-up period ranged from 4 to 52 weeks (mean, 26.7 weeks). Eleven free flaps survived completely. Two patients presented with minor dehiscence and were treated with secondary closure. Two patients developed a hematoma under the flap that required evacuation. One flap failed due to arterial thrombosis. Early free flap reconstruction proves to be a good option for the early reconstruction of blast injuries with thermal components after serial debridement and tangential excision of the wound beds.
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FUNCTIONAL RECONSTRUCTION OF ACUTELY BURNT ACHILLES TENDON WITH COMPOSITE ANTEROLATERAL THIGH FLAP WITH FASCIA LATA: A CASE REPORT
(Bakhach J., Abou Ghanem O., Bakhach D., Zgheib E. - Lebanon)
Soft tissue defects in the postero-inferior aspect of the leg are still challenging, especially when they affect the Achilles tendon due to its important functional involvement in the normal movement of the ankle. Dorsiflexion and flexion may be affected if proper reconstruction is not achieved, thus limiting daily activities such as walking, climbing stairs or running. Several techniques, including local or regional flaps, combinations of tendon substitutes with free muscular or fasciocutaneous flaps, and free composite flaps with tendon have been described for the reconstruction of complex defects caused by burn sequelae, tumors, trauma, chronic ulcers, etc. The gold standard treatment for moderate to large defects is the anterolateral thigh (ALT) flap with vascularized fascia lata. The ALT flap is reliable because of a long vascular pedicle and a large donor area. Moreover, the fascia lata mimics the Achilles tendon perfectly when rolled on itself. The aim of this article is to present the application of this technique for the first time in a case of an acute burn. The timing of reconstruction with free flaps is critical in acute burns. In our case, it was performed on the 24th day post-burn and no microsurgical complications appeared. More than six months after surgery, the patient showed a normal gait, was able to lift his own weight against gravity and no complications were detected in the donor area.
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CASE REPORT: SPONTANEOUS HEALING AND SCAR CONTROL FOLLOWING ENZYMATIC DEBRIDEMENT OF DEEP SECOND-DEGREE BURNS
(Mataro I., Delli Santi G., Palombo P., D'Alessio R., Vestita M. - Italy)
Scarring after a burn injury remains the greatest unmet challenge in the treatment of functional and psychosocial sequelae of burns. The hypertrophic scar represents the most common type of cicatrix after burns, and it has a prevalence of up to 70%. We present a case of upper and lower extremity partial-thickness burns in a female patient treated in two different modalities. Superficial seconddegree burns on the upper extremities were treated with conservative dressing with fairly early wound closure but they developed hypertrophic scars. Deeper, lower extremity burns were debrided with a new bromelain-based debriding agent, resulting in scar-free healing. The pathophysiology of hypertrophic scar formation is based on the perturbation of collagen production or degradation or both. The duration and magnitude of the inflammatory phase of wound healing also appears to play a role in hypertrophic scarring. Bromelain has demonstrated an anti-angiogenic effect in various cancer cell lines and it has been shown to regulate a variety of pro-angiogenic growth factors. This case raises the classical question of the relationship between time to healing and formation of hypertrophic scars after burn injury, pointing to other potential factors that may play an important role in burn healing.
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