The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXX	Number 1	March 2018

Summaries

4	BRÛLURES CHIMIQUES: NOTRE SÉRIE SUR 25 ANS (Levy S., Chaouat M., Malca N., Serror K., Mimoun M., Boccara D. - France) Les brûlures chimiques posent un problème diagnostic et thérapeutique car elles sont spécifiques dans leur apparence et leur évolution. Notre objectif était d'étudier les caractéristiques des brûlures chimiques. Cette étude observationnelle, rétrospective reprenait les dossiers de tous les patients admis pour brûlure chimique dans le centre de traitement des brûlés de l'hôpital Saint Louis à Paris, du premier janvier 1990 au 31 décembre 2015. Durant cette période, 162 patients ont consulté notre centre pour une brûlure chimique. Il s'agissait majoritairement d'hommes (67%) brûlés par bases (27%) dans un contexte d'accident du travail (29%). La durée moyenne entre l'accident et la consultation était de 5,36 jours. Les zones principalement atteintes étaient les mains (36%) et la surface cutanée atteinte était de 1,2% de la surface cutanée totale en moyenne. Quarante huit patients présentaient une brûlure profonde. Au total, 59 patients (36,4%) ont été hospitalisés pour une durée moyenne de 4,18 jours. Trente huit d'entre eux ont été opérés. Enfin, 92% des opérations avaient été anticipées dès la première consultation. Dans notre centre, la population touchée, les circonstances de survenue et la topographie des brûlures étaient similaires aux données de la littérature. Notre principale spécificité est la très faible surface atteinte. Cela peut être attribué aux mesures de prévention en vigueur en France, et souligne leur importance. Huit pour cent des patients opérés avaient été sous-estimés ou bien leur brûlure s'était secondairement approfondie. Ce nombre est plus faible que dans les autres séries.
9	ACUTE RESPIRATORY DISTRESS SYNDROME AMONG SEVERE BURN PATIENTS IN A DEVELOPING COUNTRY: APPLICATION RESULT OF THE BERLIN DEFINITION (Lam N.N., Hung T.D., Hung D.K. - Vietnam) Our aim was to investigate risk factors and outcome of Acute Respiratory Distress Syndrome (ARDS) in severe burn patients. A descriptive study was carried out on 159 adult burn patients with burn extent ? 20% total body surface area, treated at the Burn Intensive Care Unit, National Institute of Burns. ARDS was defined according to the 2012 Berlin definition. Risk factors for developing ARDS and outcome were recorded and analyzed. Results showed that 45 patients developed ARDS (28.3%). Severe ARDS was recorded in 30 of these patients, accounting for 66.7%. Inhalation injury, burn surface area over 40% and full thickness burn area over 20% TBSA were determined as risk factors for the development of ARDS. Mortality rate of patients with ARDS was extremely high (80%), especially for severe ARDS patients (p < 0.01), and deaths were mostly due to multiple organ failure.
13	THE TEN-YEAR EXPERIENCE OF FIREWORK INJURIES TREATED AT A UK REGIONAL BURNS & PLASTIC SURGERY UNIT (Nizamoglu M., Frew Q., Tan A., Band H., Band B., Barnes D., El-Muttardi N., Dziewulski P. - UK) Fireworks are used worldwide to celebrate national, religious, cultural festivals and holidays. However the use of fireworks is associated with preventable injuries. We aim to review cases of burns and trauma caused by fireworks presenting to a regional burns and plastic surgery unit in the United Kingdom. We hope our findings will help to guide future firework-related safety practices in the UK. A retrospective review was performed of all patients presenting to our tertiary burns and plastic surgery unit with burns and/or trauma sustained from fireworks over a ten-year period from October 2004 to October 2014. A total of 93 patients were identified. Medical case notes were reviewed, patient demographics, aetiology of injury, management and patient outcomes were recorded. A cohort of 93 patients with burn injuries caused by fireworks were identified from our database. A total of 74% injuries occurred in October and November. Mechanism of injury included contact, flash, flame burns and injury secondary to blast force. Most injuries sustained were to the hands, followed by head and neck, torso, limbs and perineum in descending order of frequency. A total of 38.7% of patients required surgery for their wounds. Fireworks not only result in significant burn injuries, but also eye injuries, soft tissue defects and fractures requiring a spectrum of plastic surgical interventions. The number and severity of accidents can be minimised by raising awareness regarding safety precautions.
17	SHEDDING OF THE ENDOTHELIAL GLYCOCALYX IS QUANTITATIVELY PROPORTIONAL TO BURN INJURY SEVERITY (Luker J.N., Vigiola Cruz M., Carney B.C., Day A., Moffatt L.T., Johnson L.S., Shupp J.W. - USA) Limited information exists regarding endothelial dysfunction following burn injury. This project aims to evaluate whether thermal injury results in shedding of the endothelial glycocalyx in a manner quantitatively proportional to injury severity, and whether the loss of intact glycocalyx is measurable in end organs. C57BL/6 mice were grouped as uninjured controls, 10% or 25% Total Body Surface Area (TBSA) scald burns. Blood and tissue sampling was performed over a specific time course. Plasma levels of shed syndecan-1, a marker of glycocalyx damage, were quantified by ELISA. Lung and spleen sections were stained with immunofluorescent anti-syndecan-1 antibodies to evaluate intact glycocalyx. Plasma syndecan-1 levels were higher in injured versus uninjured animals. Normalized levels of syndecan-1 in burned mice were significantly increased compared to hour 0 (p<0.05) at hours 4 and 8 post-injury in the 10% TBSA, and at hour 4 in the 25% TBSA group. Levels in the 10% and 25% TBSA groups peaked at hour 4 with fold change of 2.3 and 2.4 respectively. There was less pulmonary syndecan-1 immunostaining in burned animals compared to controls, and the levels inversely correlated with systemic shed syndecan- 1, beginning at hour 4 in the 10% TBSA injury group and at all time points in the 25% TBSA injury group, (0.27±0.06 and 0.14±0.04 respectively for hour 4). Similarly, there was less spleen syndecan-1 immunostaining in burned animals compared to controls at all time points. Burn injury causes shedding of syndecan-1 in a murine model, with levels correlated to injury severity and loss of the glycocalyx in lung and spleen. This work provides further insight into quantification and temporality of glycocalyx damage and systemic response to burn.
23	ENZYMATIC ESCHAROLYSIS WITH NEXOBRID® ON PARTIAL THICKNESS BURN WOUNDS: PRE- AND POST-DEBRIDEMENT HISTOLOGICAL ASSESSMENT (Di Lonardo A., Nardini V., De Rosa M., Pascone C., Graziano A., Criscuoli A.M., Ciappi S. Italy) Enzymatic escharolysis is an innovative, non-surgical treatment method for severe burn patients as it allows very early, nontraumatic removal of necrotic tissue even on patients whose overall clinical conditions would mandate delaying traditional surgical escharectomy. The aim of this work was to examine aspects related to the "quality" of enzymatic debridement, which is inherently different from surgical debridement. To this end, biopsies harvested from partial thickness burn wounds, before and after enzymatic treatment, were histologically assessed. As is well known, surgical escharectomy removes the necrosis as well as some of its neighbouring healthy tissue, sharply and radically, leaving a perfectly clean and viable wound bed. On the other hand, enzymatic escharolysis is more selective, as it completely wipes out the necrotic portion while sparing unharmed and partially damaged tissue. In this study, only mid-deep partial thickness wounds were examined, and it was observed that partially damaged dermis was always spared by the lytic action. This dermis, however, showed some "homogenization" characteristics, had few vital skin annexes in it, and therefore looked very similar to the scaffold of dermal matrices currently available on the market. This scaffold should be safeguarded with a view to possibly achieving a more complete and functional spontaneous tissue regeneration. Conversely, if this dermal portion is mismanaged, it could desiccate, thus leading to the formation of a neo-eschar with unpredictable clinical evolution. Understanding how escharolysis actually works allowed us to extrapolate fruitful usage suggestions to optimize the procedure and fully exploit its potential.
28	DELAYED AND FRACTIONAL USE OF ENZYMATIC DEBRIDEMENT WITH NEXOBRID FOR EXTENSIVE BURN INJURY: A CASE REPORT (Krauss S., Bender D., Rothenberger J., Daigeler A., Held M. - Germany) 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.
31	THE ENTITY OF THERMAL-CRUSH-AVULSION HAND INJURY (HOT-PRESS ROLLER BURNS) TREATED WITH FAST ACTING DEBRIDING ENZYMES (NEXOBRID®): LITERATURE REVIEW AND REPORT OF FIRST CASE (Di Castri A., Quarta L., Mataro I., Riccardi F., Pezone G., Giordano L., Shoham Y., Rosenberg L., Caleffi E. - Maroc) Hand burns are present in >60% of all burn cases and in fire mass casualty incidents even up to 100%. Most trauma and especially burns may be detrimental to the complex and delicate structures of the hand by direct injury, indirect BICS (Burn Induced Compartment Syndrome and interstitial high pressure) or by delayed or faulty treatment. BICS represents a special threat as the increasing swelling and oedema of the small diameter hand and forearm will exert pressure on the capillary/venous system, eventually ending in irreversible damage to the skin, nerves, muscle and vascular bed. Immediate release of constricting skin by incisional escharotomy and sometimes fasciotomy may arrest this vicious cycle: escharotomy is simple for experienced hand or burn surgeons, but they are not always present at the primary treatment site. The diagnosis of BICS is not simple either, as the direct measurement of interstitial/compartment pressure is rarely done. Burns caused by hot rollers such as industrial linen ironing machines are especially traumatic as besides the "simple" thermal burn, the hot rollers exert immense crushing pressure to the hand caught between the rollers. Over the last few years, several publications have described the role of a newly approved Bromelain derived enzymatic debriding agent (NexoBrid®) for burns in general and hand burns in particular, and its ability to resolve or prevent BICS. We present a rare severe thermal/crush hand injury case where we were able to successfully treat the patient with NexoBrid® enzymatic debridement-escharotomy.
35	RÉÉVALUATION CLINICO-BIOLOGIQUE DE L'ANTIBIOTHÉRAPIE PROBABILISTE EN RÉANIMATION DES BRULES (Moutaouakkil Y., Siah S., Bennana A., Tadlaoui Y., Makram S., Cherrah Y., Bousliman Y., Lamsaouri J. - Maroc) La résistance bactérienne est une préoccupation majeure et le bon usage des antibiotiques est une priorité de santé publique mondiale. L'utilisation inappropriée de l'antibiothérapie peut avoir de graves conséquences en termes écologique et pharmaco-économique. L'objectif de notre travail était d'étudier la réévaluation de l'antibiothérapie probabiliste au sein de l'unité de réanimation des brûlés. Une étude prospective concernant la réévaluation clinico-biologique de l'antibiothérapie à a été mise en place dans l'unité de réanimation des brûlés de l'Hôpital Militaire d'Instruction Mohammed V de Rabat. Les données ont été recueillies sur une période de 6 mois, du premier juin au 30 Novembre 2017. Pendant la période d'étude, 142 patients ont bénéficié d'une prescription antibiotique, dont 68, septiques graves, ont été inclus dans notre étude. La population est à prédominance masculine (75%). L'âge moyen de nos patients était de 36 ans avec des extrêmes allant de 15 à 56 ans. La durée moyenne de l'hospitalisation en réanimation était de 10 jours. Sur les 68 antibiothérapies mises en place, le taux de réévaluation a été de 72,06%. Les ¾ des traitements étaient justifiés, 25% non justifiées. Une désescalade thérapeutique a été réalisée dans 8 cas (11,76%) quand elle aurait pu être effectuée 25 fois (36,76%). Ceci est expliqué par la forte prévalence de BMR (Klebsiella pneumoniæ, Acinetobacter baumannii, Escherichia coli) et de Staphylocoques coagulase négatifs dans l'unité, ce qui restreint le choix de l'antibiothérapie. La réévaluation clinico-biologique de l'antibiothérapie s'avère indispensable pour lutter contre le mauvais usage des antibiotiques. Cette étude nous a amené a réaliser plusieurs actions : la désignation d'un pharmacien réfèrent en antibiothérapie au sein du Pole Pharmacie de l'hôpital militaire d'instruction Mohammed V de Rabat, l'activation d'un Comité Anti-Infectieux et la dispensation nominative des antibiotiques via Pyxis MedStation.
42	ISCHEMIC THROUGH-AND-THROUGH NECROSIS OF THE LATERAL WALL OF THE TORSO AND INGUINAL REGION SUBSEQUENT TO FLAME INJURY AND SEPTIC SHOCK: A CASE REPORT AND LITERATURE REVIEW (Tocco-Tussardi I., Presman B., Sleem Z., Huss F. - Sweden) Post-burn infections still stand as the most common/serious complication of burn injuries: sepsis accounts for 50-60% of deaths in burn patients despite improvements in antimicrobial therapies. Among the many potential complications of sepsis/septic shock are hemodynamic instability and perfusion failure. We report the case of a patient developing massive soft tissue necrosis after an episode of acute post-burn septic shock, with possible explanation of an overdosage of vasopressors due to significant body weight increase as an effect of the burn resuscitation. The utility of vasopressor agents in the management of septic shock depends on the balance between increased perfusion pressure and the direct effect on the microvasculature. The almost inevitable body weight increase in the acute post-burn phase as an effect of the resuscitation makes this balance more difficult to maintain.
47	FREY'S SYNDROME FOLLOWING A FACIAL BURN TREATED WITH BOTULINUM TOXIN (Henry N., Baker B.G., Iyer S. - UK) Frey's syndrome occurs as a result of damage to the auriculotemporal nerve, which causes inappropriate regeneration of damaged parasympathetic fibres to salivary glands to innervate the sympathetic receptors of sweat glands in the face. The symptoms are pathological flushing and sweating with gustatory stimuli. It most commonly occurs following parotid surgery and has not previously been reported following burn injury. We present a 50-year-old man who sustained 1% TBSA full thickness burn to the right side of his face as a child. This was excised and reconstructed with skin grafts as well as further revision procedures in his adult life. He incidentally reported copious amounts of gustatory sweating over his right temple region that had been present since his initial injury, occurring prior to any reconstruction, consistent with Frey's syndrome. This was confirmed with a starch iodine test, and successfully treated with Botulinum toxin injections post reconstruction. This case is the first report of Frey's syndrome following burn injury. We highlight the potential development of Frey's syndrome following facial burns, even in the reconstructed area. Botulinum toxin treatment remains effective.
49	LES COMPLICATIONS DE L'EXPANSION CUTANÉE DANS LE TRAITEMENT DES SÉQUELLES DE BRULURES (Fourati A., Ghorbel I., Karra A., Ennouri K. - Tunisie) L'expansion cutanée chez le brûlé est réputée grevée d'un taux de complications élevé. Nous avons réalisé une étude rétrospective sur une période de 8 ans (2008 - 2015) dans le but d'identifier les facteurs de risque de survenue de complications. Quarante-cinq expandeurs ont été mis en place chez 31 patients présentant des séquelles de brûlures. Nous avons noté la survenue de complications (mineures et majeures) dans 33,4% des cas. L'expansion au niveau des membres augmente d'une façon statistiquement significative la survenue de complications. Les complications semblent plus fréquentes après le 2ème temps opératoire (reconstruction). Les facteurs qui n'influencent pas le taux de survenue de complications sont l'âge, le volume de l'expandeur et l'indication esthétique ou fonctionnelle de la réparation.
54	PRISE EN CHARGE DES BRÛLÉS PAR TÉLÉ-EXPERTISE (Ravat F., Fontaine M., Poupelin J.C., Payre J., Aimard R., Lalloue C., Viard R., Gir P., Voulliaume D. - France) Fin 2013, nous avons proposé aux professionnels de santé la possibilité de solliciter un avis spécialisé H24 et 7j/7 via l'envoi de photos par courriel sur une adresse dédiée. En 2015, nous recevons une demande d'avis par jour, qui débouche sur plusieurs échanges de courriels, et le nombre de demandes est en progression constante. Cette solution de télé- expertise a permis au centre de brûlés de réguler son activité sur l'année, d'offrir aux professionnels de santé confrontés à une pathologie qu'ils n'ont pas nécessairement l'habitude de traiter l'accès rapide au spécialiste et de permettre au plus grand nombre de patients de bénéficier d'une prise en charge adaptée. La collectivité nationale en a également tiré profit : amélioration du service public et économies financières pour l'Assurance Maladie. Une solution de ce type pourrait constituer une première étape vers la mise en place d'un outil spécifique sécurisé.
59	ANALYSIS OF THE EFFECT OF SUBCUTANEOUS INJECTION OF OMENTAL-DERIVED CELLS ON THE HEALING OF THIRD DEGREE BURNS IN RATS: A PRELIMINARY STUDY (Seif F., Momeni M., Hobbenaghi R., Seif F., Mahboubi O., Babajani R. - Iran) 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).
65	HOW TO CREATE BURN PORCINE MODELS: A SYSTEMATIC REVIEW (Wardhana A., Lumbuun R.F.M., Kurniasari D. - Indonesia) Management of burn patients is challenging, and requires a lot of knowledge and experience gained through research. However, experimental study on humans is not morally and ethically accepted. Porcine is the most frequently used experimental model because pig skin is anatomically and physiologically similar to human skin. We included systematic reviews, meta analyses, and experimental studies of burns using porcine models. We excluded studies conducted more than 10 years ago and which included only thermal injuries. Burn injury made to the porcine model had to be second or third degree. Searches of Ovid MEDLINE, Pubmed, Burns Journal and Cochrane Library revealed 21 relevant studies. Three methods used to create full thickness burn wounds were found: aluminium, brass, and immersion in hot water. The aluminium bar was heated to 200°C and placed on the pig's skin for 20 seconds. For deep dermal burns, there are different methods: modified glass bottle and aluminium bar. The bottle is filled with sterile water and heated to the desired temperature (92°C), then placed on the pig's skin for 15 seconds. To measure burn wound depth, almost all the studies used histopathological evaluation. There was no standardised method to create burn wounds in porcine models. Nevertheless, for deep dermal burn wounds, we can use the modified glass bottle method and for full thickness burn wounds, we can use aluminium or brass. There are no previous studies discussing how to make burn porcine models, nor any studies in this review that focused on creating the burn wound alone. Further studies are needed to achieve better results in creating burn wounds in porcine models.
73	ARE DIRECTED ACYCLIC GRAPHS (DAGS) AN IMPORTANT TOOL TO PERFORM OBSERVATIONAL STUDIES? REFLECTIONS FROM A CASE IN BURNED PATIENTS (Machado-Rivera R.,* Mezones-Holguín E. - Peru) 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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