The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXII	Number 2	June 2019

Summaries

87	OUTCOME AND RISK FACTORS FOR DEATH OF ELDERLY BURN PATIENTS: A CASE SERIES IN VIETNAM (Lam N.N., Duc N.M., Son N.N. - Vietnam) The aim of this study is to investigate characteristics, outcome and risk factors for death among elderly burn patients. A retrospective study was conducted on 416 elderly (? 65 years old) burn patients admitted to the National Burn Hospital, Hanoi, Vietnam from 1/1/2016 to 31/12/2018. Data on demographics, comorbidity, burn severity, complications and mortality were recorded. Bivariate and multivariate analyses were conducted to determine independent risk factors for death. Results indicated that elderly burn patients accounted for 4.2% of total admitted patients with an average age of 74.7 ± 8.1 years old. Significantly higher burn surface area (12.4% vs. 7.3%; p < .001) and deep burn area (5.5% vs. 2.5%; p < .001) were seen in the female group when compared to the male group. Pre-existing medical conditions were recorded in 20.9% of patients, the highest proportion (13.2%) represented by cardiovascular disease followed by neurological and diabetic disease (8.7% and 7% respectively). Over half (51.5%) of the patients had suffered deep burn and 6.3% developed complications, the most common being multiple organ failure and pneumonia. Overall mortality rate was 9.9%. However, death rate was extremely high in patients with inhalation injury (92.9%), burn extent > 40% total body surface area (TBSA) and deep burn > 10% TBSA (61.2% and 62.5% respectively). Comorbidity was not an independent risk factor for death, unlike increased age, burn extent and presence of inhalation injury. In conclusion, we show that despite advances in management, severe burn and inhalation injury in the elderly remains a big challenge in Vietnam.
94	RESPIRATORY AND COAGULATION DYSFUNCTIONS ON ADMISSION AS INDEPENDENT PREDICTORS OF IN-HOSPITAL MORTALITY IN CRITICALLY ILL BURN PATIENTS (Aditianingsih D., Sinaga Y.B., Kartolo W.Y., Adiwongso E.S., Madjid A.S. - Indonesia) Mortality rate for burns patients in developing countries is approximately 34%. Data show that most patients in burn units will likely experience organ dysfunction. Sequential Organ Failure Assessment (SOFA) score assesses organ dysfunction and is frequently used in the ICU, but there are no previous studies regarding SOFA score in burn units in Indonesia specifically. This study was a retrospective study, conducted to assess the validity of the SOFA score in predicting mortality of critically ill burn patients in the Burn HDU and ICU of Cipto Mangunkusumo General Hospital between January 2012 to December 2017. This study included 169 subjects who met the inclusion and exclusion criteria. Medical records were used to identify the subjects' characteristics, SOFA score within 24 hours, and outcome (deceased or survived) at day 30. SOFA score validity was assessed using Area Under Curve (AUC), Hosmer-Lemeshow goodness of fit and multivariate logistic regression. The mortality rate for burn patients was 32.5%. SOFA score had very good discrimination (AUC 96.4%, CI 95% 0.933 - 0.995) and good calibration (Hosmer-Lemeshow p = 0.561). SOFA variables which had a statistically significant effect on 30-day mortality in the Burn Unit were PaO2/FiO2 ratio < 400, PaO2/FiO2 ratio < 300, PaO2/FiO2 ratio < 200 with mechanical ventilation and platelet count < 150,000/mm3 . SOFA score was a valid instrument for predicting 30 day mortality of critically ill burn patients in the Burn HDU and ICU of Cipto Mangunkusumo General Hospital, especially respiration and coagulation variables.
103	PURIFICATION AND CHARACTERIZATION OF PROTEASES FROM COW DUNG: VALIDATION OF AN ANCIENT AFRICAN HOME TREATMENT FOR BURN WOUNDS (Gololo S.S., Makhubela S.D., Tshidino T., Mogale M.A. - South Africa) Mankind has for many years relied on home remedies to manage ailments and injuries, including burn wounds. Wound healing is generally regarded as a natural process, with interventions such as ointment application regarded as assisting the process. Amongst other strategies, cow dung is a home remedy used by many African communities to manage burn wounds. The current study was aimed at the detection, purification and characterization of proteases from cow dung as validation for its usage in the management of burn wounds amongst African communities. Cow dung was collected around Pretoria, South Africa, and homogenized with a blender in a phosphate buffer, pH 7. The crude protein was obtained using ammonium sulphate precipitation and purified using size exclusion, anion exchange and cation exchange chromatographic techniques. Enzyme activity was determined using the casein digestion method. The purified proteases were characterized according to temperature and pH as well as substrate specificity. Three protease fractions were purified from cow dung homogenate. Fraction H was found to have an optimum temperature of 40?C, an optimum pH of 6 and affinity for elastin; Fraction I was found to have an optimum temperature of 35?C, an optimum pH of 7 and affinity for haemoglobin; and Fraction J was found to have an optimum temperature of 35?C, an optimum pH of 8 and affinity for collagen. The findings of the study therefore suggest that the presence of proteases in cow dung could be one of the contributing factors towards its effectiveness in traditional African burn wound management.
115	CHARACTERIZATION OF AMINOGLYCOSIDE RESISTANCE MECHANISMS IN ACINETOBACTER BAUMANNII ISOLATES FROM BURN WOUND COLONIZATION (Tahbaz S.V., Azimi L., Lari A.R. - Iran) Clinical isolates of Acinetobacter baumannii have a tendency to develop antimicrobial resistance against commonly prescribed antimicrobial agents, including aminoglycoside agents, particularly in hospitalized patients worldwide. Resistance mechanisms of the bacterium to aminoglycosides are diverse and commonly involve production of aminoglycoside-modifying enzymes and efflux systems. The aim of this study was to investigate the frequency of gene encoding aminoglycoside-modifying enzymes and expression level of adeB efflux gene in A. baumannii isolates recovered from burn wound colonization. A total of 47 clinical isolates of A. baumannii were obtained from burned patients admitted to the Burns Teaching Hospital, Tehran, in 2018. Standard antimicrobial susceptibility screening was performed to determine resistance pattern. A polymerase chain reaction (PCR) assay was performed to determine aminoglycoside-modifying genes ACC(6'), aph(3')-Via, aph(3')-IIb, aadA1, aphA1 and aph6. Semi-quantitative RT-PCR was also carried out to quantify the expression level of the adeB gene. According to the results of the present study, the acc(6') was the predominant aminoglycoside-modifying enzyme gene (80.9%), followed by aph(3')-via, aph6, aph(3')-IIb and aphA1, which was detected in 59.6%, 42.6%, 14.9% and 14.9% of isolates, respectively. None of the A. baumannii isolates harboured the aadA1 gene. The up regulation of adeB gene expression was observed in 63.8% of strains. Moreover, we indicated that there is a relationship between adeB expression and high resistance to gentamicin. Our results revealed that aminoglycoside resistance could be explained by the production of one or a combination of known aminoglycoside-modifying enzymes rather than overexpression of adeB.
122	STÉNOSE TRACHÉALE CHEZ LES BRÛLÉS : INCIDENCE ET FACTEURS DE RISQUE (Gasri B., Mokline A., Gharsallah L., Mériem L., Messadi A.A. - Tunisie) La sténose trachéale reste fréquente, surtout chez les patients de réanimation nécessitant une intubation prolongée. Dans la littérature, peu d'études se sont intéressées à cette complication chez les brûlés. L'objectif de cette étude était de déterminer l'incidence, les caractéristiques et les facteurs de risque de sténose trachéale chez les brûlés. Une étude rétrospective sur 7 ans, incluant tous les patients qui ont présenté une sténose trachéale confirmée par une exploration endoscopique et/ou radiologique, a été menée dans le service de réanimation des brûlés de Tunis. Durant la période d'étude, une sténose trachéale a été confirmée chez 20 patients, soit une incidence globale de 0,85%, et de 3% chez les patients intubés. L'âge de nos patients était de 25 ans. La brûlure était thermique avec une atteinte de la face chez tous les patients. La surface cutanée brûlée moyenne était de 33±19%. Un syndrome d'inhalation a été objectivé chez 12 patients (60%). La durée de l'intubation était de 17±14 jours. Les principaux signes évocateurs de sténose trachéale étaient dyspnée, stridor et dysphonie, avec apparaissant après un délai moyen de 30 jours post extubation. Tous les patients ont bénéficié d'une bronchoscopie et/ou d'un scanner cervico-thoracique à visé diagnostique. La sténose était en moyenne située à 27 mm des cordes vocales, avec un rétrécissement moyen de 73%. L'étendue moyenne était de 20 mm. Le traitement a été une dilatation (n=7), un calibrage (n=2) et le laser (n=3). Une résection-anastomose a été pratiquée chez 8 patients. L'évolution a été favorable chez 13 patients. Deux patients ont présenté une récidive de la sténose et cinq patients sont décédés. L'inhalation de fumées, la brûlure de la face, l'infection pulmonaire, l'étendue de la brûlure, la curarisation et le NO ont été retenus comme des facteurs de risque favorisant la survenue de sténose trachéale chez les brûlés.
130	BEAUTY IS PAIN: PEDIATRIC BURNS RESULTING FROM HAIR CURLING AND FLAT IRONS (Patel A.U., Haas J.A., Esquenazi M.D., Bell D.E. - USA) Ceramic and metal hair straightening and curling irons are common household items which reach up to 450°F in as little as five seconds. Of particular concern is the threat these devices pose to children. Our objective is to characterize and bring attention to this preventable injury in the pediatric population. Retrospective records from a high-volume level I trauma center and regional burn center from 2011-2015 were analyzed. Inclusion criteria were defined as patients <11 years of age, as those presenting with burns above this age were more likely to be utilizing the tools for hair styling. A total of 59 patients were identified with an average age of 2.4 years. The average burn size was 0.30%, with an average 0.24% 2nd degree TBSA. The etiology of the burns included touching a hair iron that was within reach (61%), pulling a hair iron's power cord (15%), stepping/rolling/jumping onto a hair iron left on the ground (17%), and hair irons falling (7%). The majority of households were comprised of unemployed (64%), single (60%) parents. CPS consult was required for 20% of patients. Grafting and excision was necessary for 20% of patients The pediatric population is at risk for accidental burns with household hair irons. These burns typically have a small TBSA, but may require excision and grafting and extended follow-up.
135	PEDIATRIC LOGISTIC ORGAN DYSFUNCTION-2 (PELOD-2) SCORE AS A MODEL FOR PREDICTING MORTALITY IN PEDIATRIC BURN INJURY (Dewi R., Christie C.D., Wardhana A., Fadhilah R., Pardede S.O. - Indonesia) Multiple organ dysfunction syndrome (MODS) is an important cause of mortality in burn injury. Pediatric Organ Logistic Dysfunction (PELOD)-2 score as a descriptive scoring system for organ dysfunction has been highly predictive of mortality in children with suspected infection, but its usefulness for burn patients is unknown. All pediatric burn patients hospitalized in Cipto Mangunkusumo Hospital (CMH) in Jakarta, Indonesia, from January 2012 to January 2017 were studied. Gender, age, nutritional status, burn characteristics, total body surface area burned (%TBSA), depth of burn, inhalation injury, time interval to resuscitation and surgery, day one ABSI and PELOD-2 score, and mortality as outcome were recorded. Bivariate and multivariate analysis logistic regressions were done to generate a mortality prediction model. Mortality rate among subjects was 20.3%. Bivariate analysis showed that extensive %TBSA, depth of burn, presence of inhalation injury, PELOD-2 score and ABSI score in pediatric burn patients were significantly associated with mortality (p<0.001). In multivariate analysis, only PELOD-2 score was independently associated with mortality. PELOD-2 score mortality prediction rate was far lower than actual mortality. Mortality rate by the new model was close to the actual mortality rate. Our new combined model could be used to calculate probability of death based on day 1 PELOD-2 score in pediatric burn patients.
143	BRÛLURE OCULAIRE SÉVÈRE PAR PROJECTION DE SOUDE (Rekik M., Kamoun S., Khrouf N., Feki J. - Tunisie) Les brûlures cornéennes représentent une pathologie fréquemment rencontrée. Celles par bases fortes, pénètrent profondément au sein du segment antérieur, sont particulièrement sévères. Nous rapportons le cas d'un patient victime de perforation cornéenne secondaire à une projection accidentelle de soude et nous proposons de discuter les particularités cliniques et thérapeutiques.
147	EFFECTIVENESS OF INCORPORATING OCCUPATIONAL THERAPY IN REHABILITATION OF HAND BURN PATIENTS (Aghajanzade M., Momeni M., Niazi M., Ghorbani H., Saberi M., Kheirkhah R., Rahbar H., Karimi H. - Iran) One of the main goals in the rehabilitation process of patients with burn to their hands is their return to society and their professional occupation, which has a direct positive influence on these patients' quality of life. The goal of this research project was to investigate the effect of early intervention with occupational therapy in patients with burns to their hands. The study included 30 patients with second or third degree hand burns. Patients were added to the study 12 days after their burn wounds and grafted areas had healed. They had 3 sessions of occupational therapy per week for 8 weeks. These sessions included active and passive range of motion exercises, active resistive exercises, stretching exercises and practicing activities of daily living. Functionality of the hand was assessed before and after the 8 weeks of occupational therapy using the DASH questionnaire. The average initial DASH score before intervention with occupational therapy was 60.9, and after 8 weeks of occupational therapy it was 33.9 (average difference between the pre-intervention and post-intervention DASH scores is 27 points, p < 0.001). After 8 weeks of occupational therapy, patients performed activities of daily living with a lot less difficulty, and an increase in functionality of the hands was observed. This study suggests that early intervention with rehabilitative therapies is advantageous and may result in improved hand function.
153	ÉVOLUTION CATASTROPHIQUE D'UNE ÉLECTRISATION DES DEUX MEMBRES SUPÉRIEURS : DÉSARTICULATION BILATÉRALE DES ÉPAULES (Aissa I., Benakrout A., Najout H., Zizi A., Bensghir M., Laalaoui S.J. - Maroc) L'importance des dégâts tissulaires secondaires aux accidents d'électrisation des membres par le courant à haute tension rend le plus souvent la gestion de ce type de brûlure très difficile. Les gestes de réparations sont parfois inefficaces et les amputations s'avèrent alors inéluctables. Nous rapportons le cas d'un jeune patient victime d'une électrisation des deux membres supérieurs avec le courant à haute tension chez qui l'évolution a été marquée par une désarticulation bilatérale des épaules.
158	INFRASTRUCTURE, RESOURCES AND PREPAREDNESS FOR MASS BURN INJURIES IN A DEVELOPING COUNTRY (Lam N.N., Tuan C.A., Luong N.V. - Vietnam) Our aims were to evaluate resources and the preparedness of the health care facilities to respond to mass burn injuries in Vietnam. A survey was conducted in 19 provincial and central/regional hospitals using a questionnaire. The contents of the survey included infrastructure, human resources, medical equipment for burn care, and preparedness of hospitals for mass burn injuries. Results indicated that a variety of burn care facilities were set up, from separate burn departments (42.1%) to burn units (15.8%) or burn beds (42.1%) inside trauma or surgical departments. Medical staff/burn bed ratio was .7 and nurse/physician ratio was 1.7, with 52.7% of nurses having more than 5 years' experience. Infrastructure and medical equipment for burn facilities were limited, with just under half of the hospitals equipped with an air conditioner and heater. Bronchoscopy for diagnosis and management of inhalation injury was available in 6 (31.6%) hospitals. Few health facilities had a mechanical ventilator, fluid warmer, hemofiltration machine, burn theater, electro-dermatome or skin mesher. Only 26.3% hospitals had a plan for the management of mass burn injuries. A burn specialist was a member of the hospital's emergency medical team in 36.8% of the hospitals. Guidelines for burn emergency care were available in 63.2% hospitals. In the last 5 years, 21.1% of health facilities had conducted a drill for mass casualty incident management, but only 1 (5.3%) hospital had conducted a drill for MBI management. In conclusion, facilities, equipment, human resources for burn care and preparedness to manage mass burn injuries in Vietnam are still limited and need to be improved.

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