The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXII	Number 1	March 2019

Summaries

3	EPIDEMIOLOGY AND THE SURVIVAL RATE OF BURN-RELATED INJURIES IN IRAN: A REGISTRY-BASED STUDY (Sarbazi E., Yousefi M., Khami B., Ettekal-Nafs R., Babazadeh T., Gaffari-fam S. - Iran) Burns are considered an important preventable fraction of injuries in low and middle-income countries, and are still a leading cause of death in Iran. This study investigates features of burns in Sina Hospital's Burn Centre in East Azerbaijan Province in order to calculate survival and mortality rates as well as factors affecting mortality in this centre. In this cross-sectional study, demographic characteristics of patients such as age, sex, cause of burns, type of burns, length of stay (LOS) in the hospital, total body surface area (TBSA), anatomic distribution of burn, mortality rate and final status of patients at the time of discharge from hospital (recovery, death) were investigated. The total mortality rate was 6.84%. Hot liquid burns and gas cylinder explosion burns were among the most common. Burns on multiple regions of the body (45.9%) and pelvic and lower limb burns (22%) constituted the next most common injury. In the TBSA index, compared to reference categories (extent of burn less than 50 percent), the categories of 50-59, 60-69, 70-79, 80-89 and over 90 percent indicated lowest survival based on the Log-Rank test. Hazard ratio for burns greater than 10% was 15.33 fold. Total body surface area burned of over 10% constantly increases the instantaneous risk of mortality therefore there is a need to enhance the quality of care provided to burn victims.
10	ÉTUDE ÉPIDÉMIO-CLINIQUE DES INFECTIONS À ENTÉROBACTÉRIES PRODUCTRICES DE CARBAPÉNÉMASES CHEZ LES BRÛLÉS (Maamar B., Abdelmalek R., Messadi A.A., Thabet L. - Tunisie) Cette étude, menée prospectivement entre janvier et juin 2017 avait pour objectif de déterminer la prévalence et les caractéristiques clinico-biologiques des infections à entérobactéries productrices de carbapénémases (EPC) survenant chez les patients brûlés hospitalisés dans le service de réanimation des brûlés. La confirmation et le typage des carbapénémases étaient réalisés avec une PCR type GeneXpert. Treize patients ont été infectés avec 7 épisodes de bactériémies, 2 pneumopathies acquises sous ventilation mécanique et 4 infections liées au cathéter, soit une prévalence de 7% des admissions. La durée moyenne du séjour en réanimation précédant l'infection était de 12 jours. Une exposition préalable aux antibiotiques avait concerné 12 des 13 patients, neuf d'entre eux étaient transférés d'autres unités de réanimation. Treize et dix patients avaient été respectivement exposés à un cathétérisme central et à une ventilation mécanique. La carbapénémase prédominante était NDM (9/15), dont la première souche de P. stuartii porteuse du gène blaNDM isolée en Tunisie. Un patient est décédé avant l'adaptation de l'antibiothérapie. Pour les autres, 13 bi-antibiothérapies adaptées ont été prescrites. Cinq patients sont morts d'infection, dont 4 malgré une antibiothérapie adaptée. L'usage de l'imipénème a été privilégié, et maintenu à chaque fois que la CMI était ?4mg/l (8 fois), en association avec : amikacine (3), colimycine (4), ou tigécycline (1). Trois patients mis sous imipénème sont décédés. La prévalence des infections à entérobactéries productrices de carbapénémases est élevée parmi les patients brûlés avec une prédominance des carbapénémase de type NDM.
17	DEVELOPMENT OF RECONSTRUCTIVE SURGERY SERVICES IN THE GAZA STRIP, PALESTINE (Al-Moghrabi A., Abu Shaban N., Ghaith J.S., Elsous A. - Palestine) Plastic surgery involves the restoration, alteration or reconstruction of the human body. It includes reconstructive and aesthetic surgery. This paper discusses the authors' experience introducing new reconstructive, microsurgical and aesthetic surgeries in the Gaza Strip. We analyzed 192 cases of reconstruction carried out in the Al-Alamy Burns Center in Al-Shifa Hospital from August 2017 to July 2018 and at the European Gaza Hospital during a one-month delegation, as well as 38 aesthetic surgeries performed in the author's private clinic. We highlight challenges hindering the development of reconstructive and plastic practices in the Gaza Strip and propose solutions. Plastic surgeries have greatly evolved at Al-Shifa Hospital. Despite obstacles limiting the development of reconstructive surgery, we were able to treat complicated cases requiring microsurgical procedures. In one year we performed 192 reconstructive surgeries, in addition to 38 hair transplants. Overall success rate was 97.8%, with five failed flaps documented. Wound infection was the main cause of failure. However, the failed flaps were repaired by various approaches. The hair transplant patients went home the same day with no complications. Plastic surgeries have improved significantly and staff competencies have increased with frequent exposure to different cases. Moreover, the physicians' skills and knowledge have been imbedded in practice following the educational development of the authors. Establishing specialized training programs in plastic and reconstructive surgery is crucial to enhancing and reinforcing the physicians' skills and knowledge and guaranteeing high quality care.
22	PRISE EN CHARGE DU PATIENT BRÛLÉ EN PRÉHOSPITALIER. PREMIÈRE PARTIE : CAS GÉNÉRAL ET INHALATION DE FUMÉES (Vaittinada Ayar P., Benyamina M. - France) La brûlure grave est une pathologie circonstancielle, le plus souvent accidentelle mais de plus en plus causée par des actes volontaires. À la phase initiale, les défaillances rencontrées sont hémodynamique, respiratoire et métabolique, plaçant l'urgentiste et le réanimateur au centre de la prise en charge initiale. Le rôle du médecin pré hospitalier est primordial mais souvent difficile, lié aux circonstances d'intervention. Les premiers gestes et traitements initiés ainsi que l'évaluation de la gravité peuvent modifier favorablement le pronostic lorsque ceux-ci sont bien menés. Dans cette mise au point nous allons dérouler les différentes étapes de prise en charge préhospitalière à mettre en place en cas de brûlure grave.
30	STATIC ELECTRICITY SPARKS HOUSEHOLD CLEANINGAGENT CAUSING FACIAL BURN (Henry N., Nijran A., Hunt J., Lewis D. - UK) Static electricity is the build up of an electrical charge secondary to the redistribution of electrons between two non-conducting materials as they rub against one another. In the domestic setting, a static discharge rarely causes significant injury, as although the voltage can be higher than normal domestic voltage (240V), the current is relatively low. However, in cases where highly flammable substances are used, the risk of a static charge causing a flash is much greater. Our institution presents the first documented case of static electrical ignition of a substance causing facial burns. While cleaning a large plastic bin sprayed with 'Ambersil', a highly flammable mould-removing aerosol spray that can be purchased for domestic use, the 60-year-old female patient placed her face inside the bin to reach the bottom and received a large flash burn to her face and right arm that was 2.5% TBSA (total body surface area) and superficial dermal in nature. She was treated conservatively and discharged. Despite advances in electrical safety in the domestic and industrial settings, there are still real risks of significant burn injuries, which manufacturers, employers and the general public should be made aware of.
33	DEPRESSION IN ADULTS POST BURN INJURY: A DESCRIPTIVE STUDY CONDUCTED IN THE BURN CENTRE OF A TERTIARY CARE HOSPITAL IN KARACHI (Ali H., Pervaiz M. - Pakistan) Burns are a major cause of psychological disability in this modern era. Psychological aspects of burn have been studied throughout the world with vast differences in results. Depression is one of the psychological illnesses that affect the individual post burn injury. Our objective was to determine frequency of depression in burn patients, burn-related factors that may contribute to the development of depression and to assess demographic distribution. Ninety-four patients from the Burns Centre, Dow University of Health Sciences & Dr. Ruth KM Pfau Civil Hospital in Karachi were selected according to specific criteria. Duration of study was from September 2017 to February 2018, with 1-40% of burns patients included through non-probability purposive sampling. Data were collected through a questionnaire consisting of consent form, demographic details and burn details. Beck Depression Inventory II was used as a scoring instrument for depression. Standard statistical measures were calculated using SPSS version 22. Out of 94 patients, 58 were male (61.7%) and 36 (38.3%) female. The most common type of burn was thermal, seen in 58 (61.7%) patients. Thirty (31.9%) patients had depression: 15 (16%) had a mild form, eight (8.5%) a moderate form and seven (7.4%) had severe symptoms of depression. Depression in 32% of cases indicates the need for diagnosis in burn-injured patients. Therefore psychiatric rehabilitation is necessary for all cases of burn in order to manage depressive symptoms, whether these symptoms are mild or severe.
37	ARDS AMONG CUTANEOUS BURN PATIENTS COMBINED WITH INHALATION INJURY: EARLY ONSET AND BAD OUTCOME (Lam N.N., Hung T.D. - Vietnam) Our aims are to determine the clinical and preclinical characteristics and outcome of ARDS among burn patients with inhalation injury. A retrospective study was conducted on 66 selected patients with ARDS, treated in the ICU of the National Burns Hospital from 11/2013 to 10/2016. The patients were divided into two groups and matched by age and burn extent: the study group consisted of 33 patients with inhalation injury and the control group 33 patients without inhalation injury. Outcome measures included blood gas criteria and oxygenation state at ARDS onset, mechanical ventilation duration, length of stay in the ICU and in the hospital, ventilation-free time and mortality rate until 28 days postburn. Results showed that ARDS onset was earlier in the study group (5.9 ±.7 vs. 9.2 ± .9 days postburn respectively; p < 0.01) and blood oxygenation disorder was more severe (PaO2/FiO2: 117.8 ± 6.1 vs. 125.9 ± 6.5 respectively; p < .01). There was no significant difference between the two groups (p > .05) regarding incidence of complications, ventilation time, ventilation-free duration, and length of stay in the ICU and in the hospital. Mortality rate until 28 days post burn was significantly higher among the study group (69.7% vs. 54.6% respectively; p < .001). In addition, time from admission and from ARDS onset to death was shorter in the study group (P < .05). In conclusion, compared to cutaneous burn-induced ARDS, ARDS in patients with inhalation injury has earlier onset, causes more severe oxygenation disorder and has a higher mortality rate.
43	BRÛLURES ÉLECTRIQUES DES EXTRÉMITÉS: DEVONS NOUSAMPUTER EN URGENCE? (Ribag Y., Achbouk A., Ouardi A., Ababou K., Fouadi F.Z., Siah S., El Khatib M.K. - Maroc) Les brûlures électriques par haute tension sont des brûlures graves. Leur profondeur s'aggrave avec le temps. Elles entraînent des dégâts tissulaires très importants, parfois irréversibles, avec des retentissements fonctionnels et esthétiques considérables surtout quand elles touchent les extrémités.1 En urgence, le chirurgien plasticien se trouve devant un challenge, doit-il amputer l'extrémité brulée en urgence, pour éviter la rhabdomyolyse, ou doit-il temporiser et attendre la délimitation des tissus nécrosés pour éviter d'avoir recours à d'autres parages ultérieurs et limiter l'amputation aux tissus nécrosés?
47	EXTENSIVELY DRUG-RESISTANT PSEUDOMONAS AERUGINOSA OUTBREAK IN A BURN UNIT: MANAGEMENT AND SOLUTIONS (Aguilera-Sáez J., Andreu-Solà V., Larrosa Escartín N., Rodríguez Garrido V., Armadans Gil L., Sánchez García J.M., Campins M., Baena Caparrós J., Barret J.P. - Spain) Infections are still the main cause of mortality in burn patients. Multidrug resistant bacteria can cause outbreaks in critical care and burn units. We describe an outbreak of infection by extensively drug-resistant Pseudomonas aeruginosa in the Burn Unit of a University Hospital in Barcelona (Spain) between April and July 2016. A descriptive study of all cases, a bacterial colonization screening of all admitted patients and a microbiological environmental study were performed in order to detect a possible common focus. Contact isolation and cohortization of healthcare workers of all infected or colonized patients were applied. Environmental control measures were instituted for possible sources of infection. The outbreak was caused by a strain of P. aeruginosa only sensitive to colistin. Ten patients were infected or colonized and two of them died. The same strain was detected in several taps and drains in different rooms of the Unit. After applying control measures, changing faucets and drains, carrying out thermal disinfection of the hot water installation of the unit, disinfecting the rooms with ultraviolet radiation and placing antibacterial filtration devices in all the taps among other measures, an effective control of the outbreak was achieved.
56	FICHES D'AUTOPOSTURES. SUPPORT PROFESSIONNEL ET INDIVIDUALISÉ (Schrével V., Chevrier E. - France) We present self-postural patterns designed to help the physiotherapist in administering his care, and tailored ones that the patient will maintain throughout the period of burn care.
64	RECONSTRUCTION OF THE BURNT NOSE USING A CARVED FLAP IN FOUR CASES (Mimoun M., Almadani O., Boccara D., Chaouat M., Al Saud N., Serror K., Haddad J. - France) Techniques for reconstructing nasal defects in burns are very limited because the surrounding scar tissue makes it difficult to use local flaps. The authors report their experience using the Converse scalping flap harvested from scarred skin, placed as a mass on the nasal area, then secondarily carved to shape the nose and covered by a skin graft. This is a retrospective study of 4 patients, 3 men and 1 woman, with an average age of 45 years, who were operated on between 1994 and 2013 using this technique for postburn nasal reconstruction. Patients had 45% burns on average. The flap was weaned from its donor site at the third week and the frontalis donor area grafted. Several months later, the flap was sculpted from the outside to the inside in the three dimensions, removing the scarred epidermal areas to restore the aesthetic units of the nose, which were grafted using a full thickness skin graft. The final aesthetic result of the nasal reconstruction was evaluated by the patient and the surgical team. The four nasal reconstructions were carried out to completion. Three were rated as 'very good' (75%) and one was rated as 'good' (25%). The Converse flap modification, referred to as the "carved flap", to reconstruct the burned nose is a reliable technique, possible on a scarred forehead with no additional donor site morbidity.
70	EFFECTS OF PROBIOTIC ADMINISTRATION ON IGA AND IL-6 LEVEL IN SEVERE BURN PATIENTS: A RANDOMIZED TRIAL (Saputro I.D., Putra O.N., Pebrianton H., Suharjono. - Indonesia) Severe burn injuries are associated with systemic inflammation or even sepsis. A beneficial effect of probiotics on burn patients is reported by regulating the function of the intestinal barrier and reducing inflammation. Immunoglobulin A (IgA) acts as an anti-inflammation antibody, and interleukin 6 (IL-6) as a pro-inflammatory mediator, released extensively in burns. The aim of this study was to investigate the effect of single and mixed strain probiotics on the level of IgA and IL-6 in severe burn patients. A randomized double-blind trial was conducted in the burn centre of the Dr. Soetomo Hospital. Severe burn patients with more than 20% total body surface area burned were randomized into two groups. Group one received a single strain and the second group received mixed strain probiotics, once daily for fourteen days. Serum levels of IgA and IL-6 were measured on day 4 post burn injury (before treatment) and day 19 (after treatment). Seventeen burn patients were enrolled in this study. IgA increased significantly from 1.01±0.67 to 1.89±0.98 mg/mL (p<0.001) in the single strain group, and 0.96±0.48 to 2.10±1.09 mg/mL (p=0.025) in the mixed strain group by paired t-test. There was no significant decrease in IL-6 in either group. No significant differences between the two groups were observed for IgA or IL-6. Administration of single and mixed strain probiotics increased IgA level, while there was no decrease in IL-6 level.

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