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TWELVE YEARS OF LYELL'S SYNDROME IN THE BURN UNIT OF SÃO JOÃO HOSPITAL CENTRE
(Barreiro D., Monteiro D., Isabel O., Silva A., Egipto P. - Portugal)
Stevens-Johnson syndrome (SSJ) and toxic epidermal necrolysis (TEN) correspond to an acute and rare life-threatening mucocutaneous reaction. We describe the etiology, length of stay, comorbidities and mortality of TEN in our hospital in a retrospective study of 12 years. Twenty-one patients were included in the study. The mean age was 66 years: 57.1% were females. One third had mucosal surface involvement. Median TBSA of epidermal detachment was 66% on day 1. Forty-two per cent had a SCORTEN at admission of 3 and 28.6% had a SCORTEN of 4, which performs 70.6% with SCORTEN ?5. The most common causes of SJS/TEN in this study were antibiotics. There were a total of 15 deaths (71.4%). All the patients in the antibiotic group died. Patients who needed invasive ventilation had higher mortality (91%) than the non-invasive ventilation group (50%) and the group on spontaneous ventilation (42.8%). The most common complications were sepsis (53%) and renal failure (23%). Highest mortality due to sepsis was in the antibiotic group. When SCORTEN score was calculated for each patient, statistical evaluation showed an increase in mortality with increasing final score. The most crucial interventions are discontinuation of the causative drug and immediate referral to a burn unit, which helps in early diagnosis and decreases mortality. Our study provides insights into the confirmation of the risk of SJS/TEN as well as its treatment. When SSJ/TEN is caused by antibiotics, the suspicion of developing fatal sepsis should be high regardless of the patient's medical condition.
TOXIC EPIDERMAL NECROLYSIS AFTER ACUTE BURN INJURY NÉCROLYSE ÉPIDERMIQUE TOXIQUE PENDANT LA PRISE EN CHARGE D'UNE BRÛLURE
(Concannon E., Kennedy S., Shelley O. - Republic of Ireland)
Toxic epidermal necrolysis is a rare, potentially fatal disorder that involves large areas of skin desquamation. Patients with toxic epidermal necrolysis are frequently referred to burn centres for expert wound management and early comprehensive critical care as this has been shown to improve patient outcome and mortality. The authors describe the first report of medication-induced toxic epidermal necrolysis occurring in a patient during acute burn management in a tertiary burn care facility. The patient sustained a 17% total body surface area flame burn to her face, chest, bilateral upper limbs and bilateral lower limbs while escaping from a wildfire. She required extensive debridement and allografting to manage burn injured areas and additional areas of epidermal loss from subsequent toxic epidermal necrolysis, amounting to a total body surface area of 90%. Definitive burn wound closure was achieved using autologous split-thickness skin grafting once donor sites healed and became suitable for harvest 3 weeks after the onset of toxic epidermal necrolysis. Grafts achieved complete take and the patient was discharged home following rehabilitation.
RISK FACTORS AND OUTCOME OF HYPERNATREMIA AMONGST SEVERE ADULT BURN PATIENTS
(Lam N.N., Minh N.T.N - Vietnam)
A descriptive study was conducted on 135 adult severe burn patients treated at the Burn ICU, National Institute of Burns from 1/2017 to 12/2017. Hypernatremia was defined as increased plasma sodium ? 146 mmol/l. It was recorded in 24.4% of total patients with onset time of 8.3 ± 4.8 days, ranging from the 5th to 21st day postburn. Moderate and severe hypernatremia was recorded in 16 (54.5%) patients. Multivariate logistic analysis indicated that increased age, burn extent, mechanical ventilation and ventilation duration were independent predictive factors for the development of hypernatremia. Significantly higher mortality rate (59.5% vs. 40.5% respectively; p = .001) and longer duration of stay in the ICU (23.2 ± 15.4 days vs. 16.2 ± 11.6; p = .01) and in the hospital (74.4 ± 43.7 days vs. 37.9 ± 22.9; p = .002) were seen in the hypernatremia group compared to normonatremic patients. It is necessary to find further effective interventions for the prevention and treatment of this fatal complication among severe burn patients.
EFFECT OF DENERVATION ON BURN WOUND HEALING
(Jurjus A., Hourani R., Daouk H., Youssef L., Bou-Khalil P., Haidar H., Atiyeh B., Saade N. - Lebanon)
The skin is a natural barrier between the interior milieu of the organism and its environment. This barrier has multiple physiological functions and may be affected by an array of pathologies including wounds and burns. The present study aims to determine the effect of the nervous system on wound healing. Specifically, this study tested the effect of denervation by chemical ablation on the burn wound healing process using guanethidine for denervation of the sympathetic postganglionic neurons and resiniferatoxin for denervation of the sensory capsaicin-sensitive fibres. Animals were divided into 8 different groups: (1) control group, (2) sensory denervated and burned, (3) sensory denervated non-burned, (4) sympathetic denervated and burned, (5) sympathetic denervated non-burned, (6) vehicle sensory burned, (7) vehicle sympathetic burned, (8) non-denervated burned. We measured different morphologic and biochemical parameters such as wound surface area, histological alterations and mast cells. In addition, NGF, IL-1?, IL-6 and IL-8 levels were determined using the ELISA technique. The gross observations, the histological data including mast cell modulation, as well as the molecular data, speak in favour of a significant delay in burn wound healing caused by sensory denervation. On the other hand, results support the positive role of sympathetic denervation in speeding up the healing process. The dual effect of the nervous system on burn wound healing is being documented in an animal model for the first time.
AUTO-TRANSPLANTATION OF AMNION-CHORION MEMBRANE IN A BURNED PREGNANT PATIENT AT TERM
(El Youssoufi A., Malonga-Loukoula E.J.L., Amouzou K.S., Diouri M. - Marocco)
Burn in pregnancy represents a threat to the mother and the fetus. Burn care in pregnant women is not well codified. An aggressive treatment including oxygen supplementation, smart fluid resuscitation and early excision has been reported. Nevertheless, auto-transplantation of amnion-chorion membrane in a pregnant woman with burns has not been reported to date. We present our first case of auto-transplantation of fresh amnion-chorion membrane in a pregnant woman admitted to our department with 14% TBSA deep and superficial burns associated with inhalation injury. The chorion-amnion membrane harvested after caesarean section was used to cover the excised and autograft sites. Outcome was good and all wounds healed. The child was healthy also.
THE EFFECTS OF PLATELET-RICH PLASMA ON HEALING OF PARTIAL THICKNESS BURNS IN A PORCINE MODEL
(Singer A.J., Toussaint J., Choi W.T., McClain S.A., Raut V. - USA)
Platelet-rich plasma (PRP) derived from autologous peripheral blood is rich in platelets that release growth factors and cytokines. We determined the effects of topically applied autologous PRP in a partial thickness porcine burn model. Partial thickness burns were created on the backs and flanks of six domestic pigs (24 burns each) using an aluminium bar preheated to 80° C for 20 seconds. After removing the necrotic epidermis, the burns were randomly treated with a topical antibiotic ointment or a single (day 2), double (days 2 and 7), or triple (days 2, 7, and 14) topical application of PRP that was prepared freshly before application. Periodic imaging and full thickness biopsies were conducted to monitor healing over 28 days. The percentage wound reepithelialization at days 11, 14, 18 and 21 did not differ significantly among the groups. By day 28 all wounds were completely (>95%) reepithelialized, and there were no differences among the groups. Time to complete healing (presented as mean, [SD]) did not differ among the groups (antibiotics, 17.1 [3.5]; single PRP, 17.6 [4.0]; double PRP, 18.4 [3.9]; and triple PRP, 17.7 [3.3] days; ANOVA P=0.43). Scar depth (presented as mean, [SD]) in mm at day 28 by treatment group was: antibiotic 5.0 [1.0], single PRP 5.5 [1.1], double PRP 5.4 [1.1], and triple PRP 5.5 [0.6], ANOVA P=0.026. We conclude that PRP results in similar rates of reepithelialization and scar depth to standard topical antibiotics in a partial thickness porcine burn model.
THE SQUARE FLAP TECHNIQUE FOR BURN CONTRACTURES: CLINICAL EXPERIENCE AND ANALYSIS OF LENGTH GAIN
(Hifny M.A. - Egypt)
Post-burn contractures, affecting the joints especially, are demanding problems. Many surgical techniques have been designated for burn contracture release. The aim of this study is to investigate the efficiency of the square flap technique to release a post-burn scar contracture, and assess the post-operative length gain that can be achieved by simple mathematical calculation. In this study, sixteen patients with linear contracture bands were treated with the square flap technique. The anatomical distribution of the contractures was: axilla, cubital fossa, flank, perineum and popliteal fossa. Scar maturity ranged from 4 months - 9 years. Square flap width and contracture band length before and immediately after surgery were recorded by simple mathematical calculation. Flap complication was assessed. Patient satisfaction was also assessed during the follow-up period. All square flaps were effective in lengthening the contracture bands. The length of the contracture that was released ranged from 2 to 6 cm. The gain in length provided with this technique ranged from 212 to 350%, average 247%, and adequate contracture release was achieved in all cases postoperatively. All square flaps healed uneventfully except for one (6%), which demonstrated limited epidermolysis that healed by secondary intention. The follow-up interval ranged from 6 months to 1.5 years. Patients or their parents were satisfied with the results of the operations in terms of skin tightness and aesthetic results. The square flap method was shown to be a simple technique and easy to replicate. It has good lengthening potential and is effective in releasing contracture bands on long-term follow-up.
RISQUE CARDIO-VASCULAIRE CHEZ LES POMPIERS INSTRUCTEURS LORS DE SESSIONS D'ENTRAÎNEMENT EN CONDITIONS RÉELLES
(Kim S-C., Lee H-J., Shin D-M., Ku B-S., Oh J-H., Cho B-J., In H., Ma J-Y. - South Korea)
Firefighting is an extreme occupation with a risk of cardiovascular disease and sudden cardiac death due to strenuous physical exertion and psychological stress during fire suppression activity. This study aimed to investigate the vital signs (hemodynamic status) and biomarkers related to cardiac disease during live firefighting activity. In this pilot case-controlled study, seven firefighting training instructors performed a live-fire simulation for 40 min in a multi-storey training tower at the Gyenoggi-do Fire Service Academy Institute. Seven participants in the control group undertook similar exercises while wearing personal protective equipment. Cardiovascular evaluation, including vital signs and related biomarkers, was done before and after simulation until 24 h later. Nonparametric statistics were used to compare between the two groups and within the simulation group. After live-fire simulation, pulse pressure, heart rate (HR) and body temperature (BT) in the simulation group were higher than in the control group (pulse pressure 74.6 mmHg vs. 53.3 mmHg, HR 110 beats per minute (bpm) vs. 77 bpm, and BT 37.6 °C vs. 36.0 °C, P < 0.05 for all). Inflammatory cytokines (IL-6), coagulation protein (fibrinogen), and stress hormones (cortisol, adrenocorticotrophic hormone) were elevated immediately after live-fire simulation, and IL-6 and fibrinogen remained elevated until 24 h after the simulation (all P < 0.05). Our exploratory analysis found increased altered hemodynamic status and stress-related biomarkers in live-fire firefighting simulations compared to controls. These markers have the potential to be used to decrease cardiovascular risk for firefighters, and warrant further investigation.
PREPARATION FOR MAJOR BURNS INCIDENTS: EVALUATION OF CONTINUING MEDICAL EDUCATION TRAINING COURSES FOR PROFESSIONALS
(Lam N.N., Huong H.T.X., Tuan C.A. - Vietnam)
The purpose of this study was to identify changes in the competence of healthcare providers who underwent training courses on the management of burns incidents. Theoretical and practical simulation training courses were conducted for 305 healthcare providers from emergency and trauma departments of general hospitals in Vietnam. Pre- and post-tests were conducted using questionnaires and with simulated practical skill evaluation by burns specialists. Results showed a significant improvement in knowledge of emergency management of burns incidents, with an increase in percentage of correct answers from 48.2% to 71.6% (p < .01). There was an average increase from 10.5% to 95.1% for the correct calculation of total body surface area involvement, and from 33.8% to 67.2% for using the Parkland formula. Increases in knowledge of resuscitation and management of inhalation injury were also noted (p < .01). For the management of major burns incidents, sufficient knowledge of the command system increased from 58.4% to 81.9%. A better understanding was gained of the missions of the Emergency Medical Team, triage and air evacuation after training (p < .001). Emergency practical skills such as CPR, ET intubation, splinting of bone fractures, burn wound dressing and using emergency medical devices also improved remarkably (p < .001) after practical simulation training. In conclusion, these results indicate that a significant improvement in the capabilities and competence of medical staff in the emergency management of burn injuries can be achieved by conducting training courses with combined theory components and practical simulation models.
COMPARATIVE PLASMA PHENYLALANINE AND GLUTAMATE PROFILES IN SCALDED RATS TREATED WITH MEBO OR COPPER (I) NICOTINATE COMPLEX
(Nassar M.A., Ali A.M.,El Din H., Omar M. - Sudan)
The time profile of total proteins and albumin in line with two amino acids, Phe and Glu, are of great importance due to their indicative value of the healing and/or deterioration of burn wounds. In this experiment, rats exposed to scalding that produced a second-degree burn were divided into four groups: control, placebo, MEBO ointment, and copper (I) nicotinate complex ointment (an antioxidant anti-inflammatory) for four weeks. The three treatments showed noticeable similarities in the Phe profiles, with a slight drop 24 hours post burn, a peak elevation by the second week, and a slight, insignificant decline by the third week, with the placebo group showing highest values over normal (P< 0.05). In the Glu profile, large differences were observed: two set profiles, one representing MEBO and copper (I) nicotinate showed one peak in the second week, and the other representing placebo showed two peaks in the first and third weeks. Albumin and total protein time profiles showed the same trend throughout the whole experiment, and are in line with a reformed metabolic state parallel to wound closure. These results reveal that MEBO and copper nicotinate have comparable effects on wound healing in scald burns, and that plasma Glu profile is a better systemic indicator reflecting the regularity and steadiness of the healing process in MEBO and copper complex treatment.
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